PULPOTOMY PROCEDURES IN PULPOTOMY PROCEDURES IN PRIMARY DENTITIONPRIMARY DENTITION

indexindex

A. DefinitionB. ClassificationC. TechniqueD. Formocresol pulpotomyE. Ca(OH)2 pulpotomy F. Other proceduresG. SummaryH. References

A pulpotomy is defined as the surgical removal of the entire coronal pulp pre-sumed to be partially or totally inflamed and quite possibly infected, leaving intact the vital radicular pulp within the canals.

The aim is to relieve pain due to pulpalgia and leave the vital pulp in roots for its completion , if incomplete (apexogenesis )

DEFINITIONDEFINITION

classificationclassification Pulpotomy

Partial pulpotomy complete pulpotomy

calcium hydroxide formocresol pulpotomy pulpotomy

CLASSIFICATIONCLASSIFICATION

Non vital pulpotomy Vital pulpotomy

Beechwood cresol Devitalization

Formocresol Preservation

Regeneration

Vital pulpotomy techniqueVital pulpotomy technique Devitalization Preservation

1. Glutaraldehyde2. Ferric sulphate

Regeneration1. Bone morphogenetic

protein2. Dentin chips

Single sitting –

FormocresolElectrosurgeryLaser

Two stage –Gysi triopasteEaslick’s formaldehydeParaform devitalising

pastePreservation

Formocresol pulpotomyFormocresol pulpotomy

Formocresol was introduced in 1904 by Buckley, who contended that equal parts of formalin and tricresol would react chemically with the intermediate and end products of pulp inflammation to form a “new, colorless, and non-infective compound of a harmless nature.”

Buckley’s formula formocresol, consists of tricresol, 19%

aqueous formaldehyde, glycerine, and water.

indicationsindications

1. Carious / mechanical exposure in vital asymptomatic tooth

2. Tooth free of radicular pulpitis3. Presence of atleast 2/3rd root length4. Absence of abscess or fistula.5. Absence of inter radicular bone loss6. Absence of internal root resorption7. Permanent posterior teeth for the expedient

treatment of pulpalgia. (it relieves pain in emergency as formocresol fixes the contiguous pulp left in the root canal.)

ContraindicationsContraindicationsLocal : -

Spontaneous pain / pain at nightPathologic mobilitySwelling or fistulaInternal resorptionLess than 2/3rd root remainingPeriapical inter radicular radiolucencyPus / serous exudate at exposure siteUncontrolled haemorrhage from amputed pulpExcesive pulp calcification

Medical : -Cardiac conditionImmunocompromised children

TECHNIQUETECHNIQUE

The formocresol pulpotomy technique was first advocated by SWEET [1930] He used a multiple sitting technique, which has been subsequently modified to either a single or two stage technique.FORMULA :- 19% Formaldehyde

35% cresol 15% Glycerin & Water

To prepare 1.5%concentration of this formula, first mix 3 parts of glycerin with 1 part of distilled water ,

then add 4 parts of this preparation to 1 part buckley’s formocresol , and throughly mix again.

Mechanism of actionMechanism of action

Formocresol causes coagulation necrosis in tissues in immediate vicinity of the application with fixation of tissue cells and micro organism.

One-Appointment One-Appointment Pulpotomy.Pulpotomy.

Indications :- only on those restorable teeth in which it

has been determined that inflammation is confined to the coronal portion of the pulp.

Contraindications :- • Teeth with a history of spontaneous pain• Profuse haemorrhage• Pathologic or internal root resorption• Inter radicular bone loss• Presence of fistulas or pus in the chamber

PROCEDUREPROCEDURE

Anesthetize the tooth and tissue.

Isolate the tooth with rubber damIsolate the tooth with rubber dam

Remove caries & determine site of pulp exposure

Remove roof of pulp chamber

Remove coronal pulp with a large Remove coronal pulp with a large excavator or a large round burexcavator or a large round bur

Apply formocresol on the pledge of cotton wool for 4 minute

Remove formocresol pledget after 4 min. & check that haemorrhage has stopped

Fill pulp chamber with cement

Restore the tooth with stainless steel crown

Take a post operative photograph

Two-Appointment Two-Appointment Pulpotomy.Pulpotomy.

Indications

(1) Evidence of sluggish or profuse bleeding at the amputation site (2) Difficult-to-control bleeding (3) Slight purulence in the chamber but none at the amputation site (4) Thickening of the periodontal ligament (5) A history of spontaneous pain without other contraindications.

Contraindications.

(1) Nonrestorable (2) Soon To Be Exfoliated (3) Necrotic.

ProcedureProcedure

1. The steps are the same as for the one-appointment procedure

2. A cotton pellet moistened with diluted formocresol is sealed into the chamber for 5 to 7 days with a durable temporary cement.

3. At the second visit, the temporary filling and cotton pellet are removed and the chamber is irrigated with hydrogen peroxide.

4. A ZOE cement base is placed.5. The tooth is restored with a stainless steel crown.

Partial pulpotomy (pulp Partial pulpotomy (pulp curretage )curretage )

It is removal of coronal pulp tissue up to the level of healthy pulp. This process is also known as partial pulpotomy.

INDICATIONS : -- when zones of inflammation has

extended more than 2 mm. in an apical direction but has not reached root pulp.

Eg. A traumatic exposure (a few days post injury in a large young pulp)

TECHNIQUETECHNIQUE1. Area is anaesthetised and isolated2. A 2 mm. deep cavity is prepared into pulp using

sterile diamond bur and copius water coolent3. Excess blood is removed by saline & small

cotton pelletes 4. Calcium hydroxide is placed onto cavity5. Sealed with ZOE reinforced IRM restoration.

IT IS RARELY SUCESSFUL AND HENCE HAS NO CLINICAL SIGNIFICANT.

REASONS FOR FAILUREREASONS FOR FAILURE Pulp is highly vascular so, even with slightest infection in any corner of pulp , the whole of it gets infected very quickly.

Its practically impossible to remove one part of coronal pulp without disturbing the other parts of it in pulp chamber.

DEVITALIZATION DEVITALIZATION PULPOTOMYPULPOTOMY

It is two stage procedure involving the use of paraformaldehyde to fix the entire coronal & radicular pulp tissue.

The medicament used have a devitalizing, mummifying, & bactericidal action.

TECHNIQUETECHNIQUEFirst appointment :-

Same as formocresol pulpotomy but place the paraformaldehyde paste in cotton pellete over the exposure & seal the tooth for 1 to 2 weeks.

Formaldehyde gas liberates from the paraformaldehyde permeates through the coronal and radicular pulp, fixing the tissue. Second appointment :-

pulpotomy is carried out with the help of local anaesthesia

ELECROSURGICAL ELECROSURGICAL PULPOTOMYPULPOTOMY

Given by mack & dean (1933 ) It is a non chemical devitalizaton technique. Electrocautery carbonizes and heat denatures the pulp & bacterial contamination After amputation of coronal pulp,the pulp stumps are cauterized through this method

Laser pulpotomyLaser pulpotomy

Jeng-fen liu et al in 1999 studied the effect on Nd:YAG laser for pulpotomy in primary teeth

GlutaraldehydeGlutaraldehyde by kopel (1979 )

Advantages over formocresol1. Superior fixative property2. Self limiting penetration3. Low antigenicity4. Low toxicity5. Elimination of cresol

2-5 % concentration

Ferric sulphateFerric sulphate

It forms a metal protein clot at the surface of the pulp stump and this act as a barrier to irritating components of the sub-base

referencesreferences

• Restorative technique for paediatric dentistry - Ms DUGGAL, MEJ CURZON, SA FAYLE, KJ TOUMBA, AJ ROBERTSON

• Endodontic – Fifth Edition - JOHN I. INGLE, LEIF K. BAKLAND

• Text Book Of Pedodontics - SHOBHA TANDON

• Clinical Pedodontics - FINN

• INTERNET ( www.google.com)