Part 14

Pulp therapy

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 Pulp therapy
Introduction:-
Many children have painful inflammation or infection of the dental nerve and pulp. This
problem is usually caused by deep dental caries. There are a variety of clinical
treatments available to remedy such problems, ranging from a minimally invasive
procedure such as the indirect pulp cap - to a more invasive procedure such as the
pulpectomy.
Appropriate pulp therapy is predicated upon the acquisition and analysis of appropriate
diagnosis data. An examination and diagnosis lead to appropriate pulp therapy
whenever a tooth pulp has been affected or infected by caries, operative exposure, or
physical (traumatic) injury. Diagnosis and treatment planning for pulp therapy in
children should include an
- appropriate medical and dental history
- visual and radiographic evaluation
- physical condition of patient

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 - additional, such as
. Palpation
. Percussion
. Tooth mobility
. Sensitivity to percussion
. Examination of mucobuccal
. Size of exposure and amount of bleeding.
. Vitality of the tooth.

Diagnostic aids in selection of teeth for vital pulp therapy:-

I. History of pain:-
The history of either presence or absence of pain may not be as reliable in the
differential diagnosis of the condition of the exposed primary pulp as it is in
permanent teeth but it should be taken into consideration in selection of the teeth for
vital pulp therapy. Information may be taken from the parents and history may be
helpful in determining the status of a painful tooth.

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The dentist should distinguish between two types of pain : provoked and spontaneous
pain (unprovoked). Provoked pain is precipitated by stimulus (thermal, chemical or
mechanical irritants) and disappear after removal of the stimulus, this denotes that
the pulp is vital and protected by a thin layer of dentine and can be treated
successfully with good prognosis (e.g. pain after hot or cold drink, pain immediately
after eating). Spontaneous pain is a throbbing constant pain that may keep the
patient awake at night. It indicates advanced pulp damage which means that
involvement of the pulp has progressed too far for treatment preserving pulp vitality
or with even a successful pulpotomy.
II. Clinical examination:-
A careful intraoral examination is extreme importance in detecting the presence of a
pulpally involved tooth.
1. Tooth mobility:-
Abnormal tooth mobility is a clinical sign that may indicate a several diseased
pulp or involvement of periodontal ligaments (pathological mobility must be
distinguished from normal mobility in primary teeth near exfoliation)
2. Sensitivity to percussion:-
Percussion should start with a very gentle and careful tap by the tip of the finger
to prevent exposing the child to uncomfortable stimuli. If
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3. Examination of mucobuccal fold:-
Presence of swelling, sinus, draining fistula or chronic abscess associated with a
deep carious lesion is a sign of an irreversibly diseased pulp (non vital pulp).
4. Size of exposure and amount of pulpal bleeding:-
Size of exposure, appearance of the pulp and amount of bleeding are the most
valuable observation in diagnosing the condition of the primary pulp.
The most favorable condition for vital pulp therapy is the small pin point
exposure surrounded by sound dentine. If the exposure is large and associated with
watery exduate or pus the tooth is not suitable for vital pulp therapy.
III. Radiographic interpretation:-
The clinical examination should be followed by a high quality periapical and bite wing
radiograph to examine periapical area and supporting bone. Pulp exposure can not
be accurately detected from an x-ray film.

Radiographic interpretation in children is more difficult than adults due

to:-
• Young permanent teeth with incompletely formed root ends giving the impression of
periapical radiolucency.
• The roots of primary molars undergoing normal physiologic resorption often present a
misleading picture or one suggestive of pathologic change.
• Permanent teeth are superimposed on the primary teeth. 5
Radiographs are valuable for determining the following
• Periapical changes such as thickening or widening of periodontal membrane space.
• Rarefaction in supporting bone.
• Presence of calcified masses within the pulp chamber and root canals.
• periapical and interradicular radiolucencies of bone.
• Depth of lesion.
• Pulp calcifications.
• Furcation involvement.
• External root resorption.
• Internal root resorption.

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IV. Vitality tests
The vitality tests are not reliable in the child dental patient in diagnosis a deep carious
lesion but it should be taken into consideration. It gives an indication of whether
the pulp is vital but it does not give a reliable evidence about the extent of the pulp
disease.
Pulp vitality tests may be used either thermal or electrical

Thermal pulp vitality test

The thermal test include the application of heat (hot gutta percha or hot
instrument) or cold (ethyl chloride or ice cone.). The reaction of a normal tooth
with vital pulp is tested first (Normal response: pain on application of hot or cold
stimulus which disappear after removal of the stimulus). If the pain persists, this
indicate pulpitis. If the pulp does not respond to thermal stimuli (the child does
not feel any pain) this is an indication of non vital pulp.

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Electric pulp tester
It is an apparatus used to test pulp vitality.
Record the reading of a normal tooth with vital pulp first, then record the reading of the
carious one. If the pulp of the affected tooth responds at lower reading than normal
this denotes hyperemia or pulpitis. If it rsponds at a higher reading than normal this
is an indication of pulp degeneration.
Disadvantages of electric pulp tester
• Electric irritation on the pulp
• False positive result when content of pulp is liquid in case of liquefaction necrosis
(the pulp is non vital although it responds at a lower degree).
• The child might be apprehensive and the dentist lose child„s confidence causing
disruptive behavior.
V. Physical condition of the patient:-
Successful pulp therapy is dependent in some measures at least upon the absence of
systemic disturbance that might exert a deleterious effect on the pulp. Seriously ill
children, suffering from heart disease, nephritis, leukemia, tumors, cyclic
neutropenia should not be subjected to the possibility of acute infection resulting
from pulp therapy aside from the fact that pulp might not possess normal
regeneration power. Extraction of the involved tooth after proper permedication with
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antibiotics is the treatment of choice in such serious diseases.
Vital pulp therapy:-
Pulp capping:-
The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing either
directly on the exposed pulp (direct pulp capping) or on a thin residual layer of
slightly soft dentine (indirect pulp capping).
Techniques of vital pulp therapy
1. Indirect pulp capping
2. Direct pulp capping
3. Pulpotomy (formocresol)
a- One visit
b- Two visit
4. Partial pulpectomy

Techniques of non vital pulp therapy:-

1. Pulpectomy (complete)
2. Non vital pulpotomy
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 Indirect pulp capping
Definition:-
It is the procedure taken to protect or maintain the vitality of a deep
carious tooth and the decay is completely excavated without pulp
exposure

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Indications:
1. When a tooth has a deep carious lesion in which the total removal of all
carious dentine would most certainly result in large pulp exposure.
2. This pulp exposure necessitating complex and expensive treatment.
3. There is no root resorption.
4. Absence of mobility.
5. Absence of periapical inflammation radiographically.
6. Absence of spontaneous pain

Contraindications for the Indirect Pulp Cap

• Prolonged spontaneous pain, particularly at night.
• Excessive tooth mobility.
• Parulis in the gingiva approximating the roots of the tooth.
• Widened periodontal ligament space, interradicular or periapical
radiolucency.

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Procedure:-
First visit:-

 Without local anesthesia nor rubber dam application, excavation of the

superficial layer of caries is done up to the last thin leathery dentine layer by
excavator or large round bur slow speed avoid pulp exposure.
 The remaining carious dentine is dried (the copping material will not adhere
on wet surface).
3. The remaining thin layer of caries covered with a bacteriocidal dressing.
Usually the recommended material are either zinc oxid_eugenol or calcium
hydroxide which they have the following properties:-
a- Kills bacteria present in carious lesion.
b- Prevent progression of caries toward the pulp i.e arrestes carious process
c- It promots sclearosis of remaining dentine enhancing formation of reparative
dentine.
4. The over hanging walls of enamel should be left as such because it provides
retention for the dressing.
5. The cavity is filled with zinc phosphate cement or fortified zinc oxide eugenol
and left as such for 6-8 weeks. 12
Treatment can be judged successful if:
1. The restoration was intact.
2. The tooth was not sensitive to percussion.
3. No history of pain after treatment.
4. No radiographic evidence of radicular diseases.
5. No radiographic evidence of root resorption
6. No clinical evidence of direct pulp exposure when
the tooth was reentered and the residual carious
dentine was examined or excavated

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Second visit: 6-8 weeks later:-
during this waiting period
1. The caries process in the deep layer will become arrested and soft caries is
hardened.
2. A protective layer of reparative dentine has been formed.

Procedure in second visit:

1. The tooth is anesthetized and isolated with rubber dam.
2. Carefully remove remaining carious dentine, which is somewhat
hardened and
3. The cavity preparation is completed in the conventional manner and
4. The tooth is restored as usual.

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 Direct pulp capping
Definition:-
Direct pulp capping is the procedure of covering the exposed vital pulp tissue by a
material which promote healing of the vital pulp tissue that has been inadvertently
exposed from caries excavation or traumatic injury.

Indication:-
1. Recent traumatic exposure or mechanical exposure (during cavity preparation).
2. Small pinpoint exposure surrounded by sound dentine.
3. Shallow exposure.
4. Vital pulp free from infection.
5. No bleeding at the exposure site or an amount that would be considered normal.
6. No hyperemia or inflammation.
7. No clinical nor radiographic evidence of pulp pathology.
8. Young permanent teeth with incompletely formed apices to permit the continued
root formation and apical closure.

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Contraindications for the direct pulp capping:-
1. Carious exposure.
2. Spontaneous and nocturnal toothaches.
3. Excessive tooth mobility.
4. Thickening of the periodontal ligament.
5. Radiographic evidence of furcal or periradical degeneration.
6. Un controllable hemorrhage at the time of exposure.
7. Purulent or serous exudate from the exposure.

Direct Pulp Cap Requirements:

• -The capping material must prevent bacterial microleakage.
-The capping material must directly contact pulp tissue to exert a
reparative dentin bridge response.
-Investigations support the use of hard-set calcium hydroxide cements.
-Success rate 80% for well-chosen cases.
-An alternative material: Mineral trioxide aggregate (MTA). The material
consists of tricalcium silicate, tricalcium aluminate, tricalcium oxide, and
silicate oxide.
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Procedure: (Technique):
 Anesthetized and isolate with rubber dam or cotton rolls.
 If traumatic exposure occur during cavity preparation may be
a- the necrotic (carious) material is not introduced so
-Irrigate
-Capping
b- the necrotic (carious) material is introduced into the pulp tissue so
-Enlarge the exposed site to
. allow carious fragments be easily washed away
. facilitates direct contact of capping material with pulp tissues.
3. Irrigating solution as normal salaine or chloramine T to clean area and keep pulp
moist while the blood clot is forming before the placement of the capping
materials
4. Calcium hydroxide is the material of choice of capping exposed vital pulp tissue.
5. Zinc oxide-eugenol is placed over the calcium hydroxide layer as a sealant, then
6. Zinc phosphate cement and
7. The permanent restoration is inserted at the same appointment.
8. Direct pulp capping is not encouraging in primary dentition. Because :-
a- The success of pulp capping depends uppon the presence of young, active
undifferentiated mesenchymal cells which can be induced to transform into odontoblasts.
b- In primary dentition, pulp tissue ages early and less cellular elements are available
c- Moreover, some cell may transfer to odontoclast causing internal resorption.
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Formocresol pulpotomy:-
Formocresol solution releases formaldehyde which diffuse through the pulp and by
combining cellular protein fixes the pulp tissue.
Definition:-
The surgical removal of the entire coronal pulp for
primary tooth, leaving intact the vital radical
pulp within the canals.
Indications:-
1. Cariously exposed primary teeth, when their retention is more advantageous than
extraction.
2. When inflammation is confined to the coronal portion of the pulp.
3. Wide old exposure.
4. Controlled bleeding at the amputation site.
5. No history of spontaneous pain.
6. Normal clinical and radiographic sign.

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Contraindication:-
1. Spontaneous throbbing pain, particularly at night.
2. Swelling, fistula and sulcular drainage.
3. Tenderness to percussion.
4. Abnormal mobility
5. Internal resorbtion
6. Pulp calcification (pulp stones).
7. Physiologic external root resorption more than one third (1/3) or tooth in away of
shedding.
8. Periapical or interradicular radiolucency.
9. Excessive pulpal bleeding or putrescent odor.
10. Non restorable tooth.
Types of formocresol pulpotomy:
1. The one step technique (one visit technique).
2. The two steps technique (two visit technique).
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The one step technique:-
1. Profound anesthesia for tooth and tissue.
2. Isolate the tooth to be treated with a rubber dam
3. Access opening – Excavate all caries.
4. Remove the dentine roof of the pulp chamber.
5. Remove all coronal pulp tissue with slow speed round bur or sharp spoon
excavator.
6. Achieve hemostasis with dry cotton pellets
7. Apply diluted formocresol to pulp on cotton pellet for 3-5 minutes (covering the
radicular pulp stamps).
8. Do not allow the solution to lack on the gingival tissue.
9. Prepare a paste of inforced zinc oxide-eugenol
10. Remove the cotton pellet and place just enough paste to cover the radicular pulp
stumps.
11. Pressure should be avoided on radicular pulp tissue.
12. After setting of zinc oxide eugenol base, the tooth is ready for final restoration.
13. Place final permanent restoration.
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Alternatives to using formocresol in primary teeth:-
a. Formocresol: 1) fixative; 2) chronic inflammation; 3) possibly mutagenic or
carcinogenic; 4) 83% success rate.
b. Glutaraldehyde: 1) superior fixation by cross linkage; 2) diffusibility is limited;
3) excellent antimicrobial agent; 4) causes less necrosis of pulpal tissue; causes
less dystrophic cacification in pulp canals.
c. Ferric sulfate: 1) astringent; 2) forms a ferric ion-protein complex that
mechanically occludes capillaries; 3) less inflammation than F.C; 4) 92%
success rate.
d. Electrosurgery and laser:- less successful than ferric sulfate or dilute formocresol.
e. Using MTA paste (obtained by mixing MTA powder with sterile saline at a 3/1
powder saline ratio.
-IRM is place over the MTA.
-Promising

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The two steps technique:-
1. After amputation of the pulp and formation of a healthy clot.
2. A pellet of cotton with formocresol is placed over the floor of pulp chamber and
cover it with temporary dressing.
3. After 2-3 days (the second visit)
a- Isolate the tooth with rubber dam without local anesthesia (now the surface of
the pulp tissue is fixed and not sensitive).
b- Remove the dressing and the pellet of cotton previously moistened with
formocresol and
c- complete the procedure as before in the one visit technique.
N.B.:- A chrome steel crown is the ideal restoration after pulpotomy because the
crown of the tooth treated by pulpotomy is weak, brittle and might split fracture.
N.B.: If there is any sign of hyperemia following removal of coronal pulp (pain or
excessive hemorrhage) indicating that inflammation is present in the tissue
beyond the coronal portion of the pulp. Pulpotomy should not be performed but
do partial pulpectomy or even extraction of the tooth.

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Partial pulpectomy
Definition:-
It is the removal of coronal pulp tissue and as much
as possible from the contact of the root canal
Indications:-
1. It is indicated in the primary molars due to
a- morphology of the root canal such as lateral branching and ramification.
b- presence of accessory root canal where removal of the all the contact of the radicular
pulp tissue is impossible.
2. When the coronal pulp tissue and the tissue entering the pulp canals are vital but
show clinical evidence of hyperemia.
3. The tooth may or may not have a history of painful pulpitis
4. No evidence of necrosis (suppuration).
5. Radiographically, there should be no evidence of a thickened periodontal
ligament or radicular diseases.

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Technique:-
The technique is completed in one appointment
1. Remove the coronal pulp tissue (same steps in pulpotomy).
2. Remove as much as possible from the contact of root canal
with a serrated broach, care should be taken not to penetrate
the apex (Root canal instrument placed in special hand piece
may be used for root canal debridement with extreme care).
3. No widening of the root canal
4. Irrigation of the canals with normal saline or mild antiseptic solution (hydrogen
peroxide or sodium hypochlorite).
5. Dry the canal with sterile paper points.
6. The root canal may be filled with zinc oxide-eugenol or oxypara or any other
restorable material which will be resorbed as normal root resorption
7. Filling the root canals:-
a- A thin mix of zinc oxide-eugenol past may be prepared and paper points covered with
material are used to coat the root canal walls.
S mall K files may be used file the paste into the walls, the excess thin paste may be
removed with paper point or head strome files.
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 b- A thick mix of the zinc oxide-eugenol should be prepared, rolled into a point of file and
carried into the canal,
c- Root canal plugger may be used to condense the material into the canals.
d- Zinc phosphate is put as a base and .
f- An x-ray film may be necessary to allow evaluation of the success of filling the canals.
e- The tooth should be restored with permanent restoration and chrome steel crown.

Technique of non vital pulp therapy:-

1. Pulpectomy (complete)
2. Non-vital pulpotomy

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1. Complete pulpectomy (endodontic treatment):-
Definition:-
the removal of necrotic pulp tissue followed by filling the root canals with resorbable
material (cement).
Fist:- Pulpectomy of the primary molars is often considered impracticable because of:-
a-the difficulty of obtaining adequate access to the root canals in the small mouth
of the child.
b-the complexity of the tooth and pulp morphology in primary molars as:-
-An increase number of accessory canals, foramin and porosity in pulpal floors of
primary teeth.
-Primary root canals are more ribbon-like.
-Fine, filamentous pulp system.
-More difficult canal debridement.
-Complete extirpation of pulp remnants almost impossible. Increased potential of root
perforation.
-Root canal opening is several mm coronal to the radiographic apex.

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Second:- Endodontic procedure for the treatment of primary teeth with necrotic pulps
are indication if the canals are accessible and if there is evidence of essentially
normal supporting bone. So the commonist teeth treated by this way are primary
anterior teeth.
Treatment objectives for primary tooth pulpectomy:-
1. Maintain the tooth free of infection.
2. Biomechanically cleans and obturate the root canals,
3. Promote physiological root resorption, and
4. Hold the space for the erupting permanent tooth.

Indications for pulpectomy of primary teeth:-

1. Cooperative patient
2. Teeth with poor chance of vital pulp treatment
3. Strategic importance for vital pulp maintenance
4. Absence of sever root resorption
5. Absence of surrounding bone loss from infection
6. Expectation 29
7. Pulpless primary teeth with sinus tracts
8. Pulpless primary teeth in hemophiliacs
9. Pulpless teeth next to the line of a palatal cleft
10. Pulpless primary teeth when space maintainers or continued supervision are not
feasible (handicapped children).
Contraindications for primary tooth pulpectomy
1. Tooth with non restorable crown
2. Periradicular involvement extending to the permanent tooth bud
3. Pathologic resorption of at least one third of the root with a fistulous sinus tract
4. Excessive internal resorption
5. Extensive pulp floor opening into the biforcation
6. Systemic illness such as congenital or rheumatic heart disease, hepatitis,
leukemia, or child on long-term corticosteroid therapy those who are
immuncompromised
7. Primary teeth with underlying dentigerous or follicular cysts.

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An ideal root canal filling material for primary teeth should:-
1. Exhibit resorption at the same rate as the primary root structure.
2. Demonstrate rapid resorption of any sxcess material extruded beyond the root
apices
3. Be antiseptic
4. Fill the root canals easily
5. Adhere to the canal walls
6. Not shrink
7. Be easily removed, if needed
8. Be radioopaque
9. Not discolor the tooth
10. Be nontoxic

Currently, no material meets all these criteria. Zinc oxide eugenol is presently
the most commonly used root canal filling material for the pulpectomy procedure
in primary teeth.
Other root canal filling materials for primary teeth include calcium hydroxide,
iodoform paste, or a combination of both or kripaste. 31
Clinical technique for primary tooth pulpectomy
1. Isolate with rubber dam and
2. Enter pulp chamber
3. Extripate the pulp with broaches
4. Irrigate with normal saline or sodium hypochlorite
5. With a 15 endodontic file to remove disease pulp tissue. Use as long a file as dictated by
the size of the canal. File is short of radiographic apex, a rubber stopper is used as marker
instrument only to point of resistance. Size 35 = largest file size for primary teeth.
6. Remove organic debris; irrigate periodically with dilute sodium hypochlorite or saline.
7. Dry the canals with paper points.
8. Obturate with ZOE or resorbable kri paste
9. A thin mix of ZOE carry into the canals using either paper point, a syringe, or a lentulo
spiral root canal filler or any other suitable instrument.
10. A thick mix of ZOE with suitable instrument
11. Zinc oxide-eugenol paste has been condensed to the apices.
12. Fill the remainder of pulp chamber with a reinforced ZOE or glass ionomer.
13. Restor with a restoration such as stainless steel crown or composite type crown.

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1. Non vital pulpotomy:
Ideally a non-vital tooth should be treated by pulpectomy and root canal filling.
However pulpectomy in primary molars is extremely difficult and often not
practical. A non-vital pulpotomy method is advocated.
Technique of non vital pulpotomy:-
First visit
1. Necrotic coronal pulp is removed as pulpotomy and
2. Infected radicular pulp is treated with strong antiseptic solution such as:-
- Beech wood cresote
- Formocresol comforated monochlorophenol.
3. The material is applied cotton pledgt and sealed in the pulp for 1-2 weeks
4. Put temporary filling

The strong antiseptic action of these solutions combats

infection in the radicular pulp.

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Second visit:-
1. The antiseptic solution is removed and replaced by antiseptic paste (eugenol +
formocresol + zinc oxide powder).
2. Press antiseptic paste firmly into the root canal with a cotton pellet
3. Pressure forces the past down the root canal compressing the pulp tissue apically
4. Then restore the tooth as usual (chrom steel crown).

N.B.
The presence of a sinus associated with chronic abscess or of some degree of tooth
mobility is not a contraindication for this method.
A sinus is expected to disappear following control of infection and a mobile tooth
becomes firm as a periapical bone reforms
A tooth with acute abscess may be treated by this method after draining the pus and
controlling the infection.

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Pulp therapy for young permanent teeth
1) Vital pulpotomy (Apexogenisis):
Apexogenesis is a histological term that has been used to
describe the result of vital pulp procedures that allow
the continued physiologic development and
formation of the root‘s apex in vital young permanent teeth.
Indications:-
1. Treatment of young permanent teeth with carious exposure with immature root
development (incomplete root formation). But with healthy (vital) pulp tissue.
2. Exposed teeth with no symptoms of painful pulpitis
3. Pulp exposure resulting from crown fracture.
4. Clinically:-
-No abscess
-No fistula
-No extreme mobility
-Large carious lesion or mechanical /traumatic exposure
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5. Radiographic:-
-Probable exposure
-Normal bony structures around the tooth
-Incomplete root development
-No internal or external root resorption

Objectives of Apexogensis:-
1. Preserve radicular vitality
2. Maximize the apportunity for apical development and closure.
3. Enhance continued root formation
4. Promote tertiary dentine formation
5. No evidence of inflammatory resorption
6. No evidence of root and periradicular pathosis

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Clinical technique for pulpotomy of young permanent tooth:-
1. Anesthetize the tooth and isolate under a rubber dam.
2. Excavate all caries and establish a cavity outline.
3. Irrigate the cavity and lightly dry with cotton pellets.
4. Remove the roof of the pulp chamber.
5. Amputate the coronal pulp with large low-speed round bur or excavator.
6. Control hemorrhage with a cotton pellet or adamp pellet of hydrogen
7. Place a calcium hydroxide over the radicular pulp stamp. This stimulates a
calcific response immediately adjacent to it, which is seen later on as radiographic
“bridge” over the amputation site.
8. Place quick-setting Zinc oxide eugenol cement or resin-reinforced glass ionomer
cement over the cacium hydroxide to seal and fill the chamber.
9. Restoration with composite resin temporarily to prevent fracture.

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10. If degenerative and irreversible coronal pulp changes have not progressed into
radicular pulp, successful root closure can progress to completion
a- A periodic radiograph re-evaluated every three months for the first year and then every 6
months for 2-4 years to determine if successful root formation is taken place and to
confirm that no pathologic periapical changes are present, root resorption and periradicular
pathosis.
b- Also periodic clinical evaluation is mandetory.

1) Apexification (Root end closure in non vital permanent

tooth)
Definition:-
The immature permanent tooth that develops pulpal or periapical disease presents
special problems. Because the apex has not closed and may be wide open,
conventional root canal treatment procedures are not indicated and would be
unpredictable. So the process of creating an enviroment within the root canal and
periapical tissues after pulp death that allows a calcified barrier to form across the
open apex.

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Objectives for apexification
1. Apexification is used to promote root elongation
2. Lead to calcification root closure (apical closure). Even though the pulp has been
necrotic and is removed, Hertwig‘s epithelial root sheath is tough to persist and be
capable of generating the response.

Indications:-
1. Apexification is required for un immature permanent tooth with pulp necrosis.
2. The tooth must be ultimately restorable.

Contraindication:-
1. All vertical and most horizontal root fracture.
2. Replacement resorption (ankylosis).
3. Very short roots.

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Technique:-
1. Isolation with rubber dam and surface disinfection.
2. Access opening larger than normal to allow removal of all necrotic tissue.
3. Removal of necrotic pulp by inserting, rotating, and withdrawing a large barbed broach or
a large file.
4. Determination of working length to slightly short of the radiographic apex.
5. Irrigation with normal saline or sodium hypochlorite.
6. Dry with paper point.
7. Calcium hydroxide powder with barium sulfate added for radiopacity (9:1 ratio) is mixed
with saline (or local anesthetic or glycerin) to form a stiff past. This is introduced with flat
plastic instrument condensed with large plugger marked at the working length.
8. Coronal seal we can use an antibacterial material and good sealer for wall such as like
flortified zinc oxide-eugenol cement.
9. It may be covered by composite resin to restore the fracture.]
10. Recall schedule: The calcium hydroxide gradually washout, therefore, it must be replaced
every several months till apical closure occure.
11. Obturation:- If the root completed and the apex closed a root canal filling is done.

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