Blackwell Publishing AsiaMelbourne, AustraliaAEJAustralian Endodontic Journal1329-19472006 The Authors.
Journal compilation © 2006 Australian Society of Endodontology20063227578Case ReportApexo-
genesis after pulpotomyM. Parirokh and S. Kakoei
C A S E R E P O RT
Vital pulp therapy of mandibular incisors: a case report with
11-year follow up
Masoud Parirokh, DDS, MSc1 and Shahla Kakoei, DDS, MSc2
1 Endodontics Department, School of Dentistry, Kerman University of Medical Sciences, Kerman, Iran
2 Oral Medicine Department, School of Dentistry, University of Medical Sciences, Kerman, Iran
Keywords
apexogenesis, calcium hydroxide, crown
fracture, pulpotomy, vital pulp therapy.
Correspondence
Dr Masoud Parirokh, Department of
Endodontics, School of Dentistry 76186, Shafa
Ave, Jomhory Blvd, Kerman, Iran. Email:
masoudparirokh@yahoo.com
doi: 10.1111/j.1747-4477.2006.00021.x
Introduction
Traumatic injury is a common cause of pulpal damage in
anterior teeth. Crown fractures involving enamel, dentine
and pulp have been termed complicated crown fractures
by Andreasen and Andreasen (1). The degree of pulp
involvement can vary from a pinpoint exposure to a total
unroofing of the coronal pulp (2).
Crown fractures with pulp exposure represent 2% to
13% of all traumatic injuries that involve the teeth (2).
The majority of these injuries occur in recently erupted or
in young permanent teeth that have immature roots.
Accordingly, treatment is oriented towards preserving
pulp function (3).
Pulp preservation by vital pulp therapy includes pulp
capping and pulpotomy. Both procedures permit preser-
vation of pulp tissue for continued root development.
The goals of pulpotomy to produce apexogenesis are:
1. Sustaining a viable Hertwig’s epithelial root sheath,
thus allowing continued development of root length for a
more favourable crown-root ratio.
2. Maintaining pulpal vitality, allowing the remaining
odontoblasts layer to lay down dentine, producing a
thicker root and decreasing the chance of root
fracture.
3. Promoting root end closure, creating a natural apical
construction for obturation, if necessary.
© 2006 The Authors
Journal compilation © 2006 Australian Society of Endodontology
Aust Endod J 2006; 32: 75–78
Abstract
This report describes a case of a young patient in whom all the mandibular inci-
sor teeth suffered complicated crown fractures because of a car accident. For all
mandibular incisors, pulpotomy with calcium hydroxide were performed in
order to achieve apexogenesis and the teeth were restored with a double-seal of
glass ionomer cement and composite resin. The patient was reviewed over 11
years. All the mandibular incisor teeth showed continued root development
and complete apex formation. Pulp canal obliteration was observed in only the
mandibular right central incisor.
4. Generating a dentinal bridge at the site of the pulpot-
omy; however, bridging is not essential for the overall
success of the procedure (3).
Treatment planning is influenced by tooth maturity and
the extent of the fracture. Every effort must be made to
preserve pulps in immature teeth. Conversely, in mature
teeth with extensive loss of tooth structure, pulp extirpa-
tion and root canal therapy are prudent before post and
core and crown restoration (2).
It has been generally considered that many traumatised
teeth eventually undergo extensive calcification of the
canal (3). Some reports indicate the need for root canal
treatment because of possible necrosis, continued cal-
cification, or internal resorption after pulpotomy (4–6).
However, others claim histologic data are insufficient to
provide sufficient evidence for recommending root canal
treatment after partial pulpotomy (7–9).
The purpose of this case report is to describe a case in
which vital pulp therapy for exposed mandibular incisor
pulps was performed and where after a long period the
teeth were clinically and radiographically evaluated.
Case report
An 8-year-old girl attended our clinic because of trauma
that caused complicated crown fractures in all the man-
dibular incisors. This examination was performed 10 h
75
Apexogenesis after pulpotomy M. Parirokh and S. Kakoei

Figure 1 Radiographic image of mandibular incisors after trauma.

Figure 3 Radiographic image of mandibular incisors 6 months after first

treatment.

Figure 2 Radiographic image of the teeth immediately after

apexogenesis.

after the car accident that caused the trauma. A medical

and dental history was taken. Clinical and radiographic
examination was performed and this ruled out any root
fractures. Examination revealed that all mandibular inci-
sors had immature apices and exhibited pulp exposures
(Fig. 1). Under local anaesthesia with 2% lidocaine and
1:80 000 epinephrine, (Darupakhsh, Tehran, Iran), cervi-
cal pulpotomies were performed in all the mandibular Figure 4 Mandibular incisors 11 years after apexogenesis.
incisor teeth using a diamond bur (Diatech, Heerbrugg,
Switzerland). The pulps were covered with pure calcium
hydroxide powder (Merck, Darmstadt, Germany) that up for clinical and radiographic evaluation. Radiographic
was mixed with physiologic saline (Samen Industries, images showed root development (Fig. 3). After that,
Mashhad, Iran) to a very dry thick mix and which was owing to the patient’s moving to another city, it was not
condensed with a light, vertical pressure to a thickness of possible to regularly follow up the patient. After 11 years,
2–3 mm. however, the patient came back to the office to take advice
The teeth were restored with glass ionomer cement because of composite resin restoration discoloration. The
(Fuji, Japan). After 1 week, part of the glass ionomer was patient was symptom-free and comfortable. A radio-
removed and the teeth and their crowns were restored graphic image (Fig. 4) showed that all of the teeth
with light-cured composite resin (King Dental Corp., had favourably developed and there was no evidence of
USA) (Fig. 2). Six months later the patient was followed either resorption (internal or external) or periradicular

76 © 2006 The Authors

Journal compilation © 2006 Australian Society of Endodontology
M. Parirokh and S. Kakoei
pathologic changes. Pulp canal obliteration (PCO) was
only observed in the mandibular right central incisor. The
patient was referred to a prosthodontist for replacement of
the coronal restorations.
Discussion
Pulpotomy is generally regarded as the treatment of
choice for immature permanent incisor teeth with exten-
sive exposed vital pulp tissue. This treatment preserves
pulpal function, thus allowing continued root develop-
ment (3,10). A modified pulpotomy technique (Cvek
type) has shown itself to be more predictable. This pul-
potomy technique may be termed shallow or partial
pulpotomy. The deep pulpotomy technique is difficult
technically and often fails to produce what pulp therapy
should: preservation of pulp tissue in the critical cervical
area of the tooth, where subsequent fractures can occur in
thin, weak walls of pulpless teeth (2). It has been sug-
gested that partial pulpotomy, as compared with cervical
pulpotomy, has many advantages including the preserva-
tion of cell-rich coronal pulp tissue, a necessary element
for better healing, and the physiologic apposition of den-
tine in the coronal area. In contrast, cervical pulpotomy
removes all the coronal pulp, leaving the crown without
the physiologic apposition of dentine, thereby increasing
the risk of cervical fracture (2). Today, it is generally
accepted that apart from special situations, cervical pulpo-
tomy is no longer indicated when the more favourable
prognosis for partial pulpotomy or pulp capping is consid-
ered (2,10). In the present case, cervical pulpotomy was
performed for all mandibular incisors because the exten-
sive crown fractures did not allow enough space for a
shallow pulpotomy and coronal restoration.
Various reports have demonstrated that dental pulp tis-
sue has an inherent capacity for soft tissue healing and
hard tissue bridge formation under a variety of dental
materials (11–15). In addition to calcium hydroxide, min-
eral trioxide aggregate and adhesive resins have recently
been introduced for vital pulp therapy (11,12).
Since the 1980s, calcium hydroxide has clearly been the
material of choice because it elicits the formation of a den-
tinal bridge, following a number of phenomena. Calcium
hydroxide is thought to cause a coagulation necrosis,
inducing a low-grade irritation that leads to differentiation
of the undifferentiated pulp cells. These cells synthesise
predentine, which is subsequently mineralised, while the
coagulated tissue is calcified (16). Many different types of
calcium hydroxide materials have been introduced to the
market for vital pulp therapy. It has been demonstrated
that hard-setting calcium hydroxide cements such as
Dycal® set rapidly in the presence of moisture and, conse-
quently, do not allow easy placement onto exposed pulps
© 2006 The Authors
Journal compilation © 2006 Australian Society of Endodontology
Apexogenesis after pulpotomy
(17). In this case, therefore, pure calcium hydroxide was
used for covering pulp exposures.
The presence of bacteria and their by-products is one of
the most important reasons for failure of vital pulp therapy
(18). It has been suggested that along with pulpal health,
provision of a seal against bacterial ingress is probably the
most critical factor in the success of vital pulp therapy
(11,12). In a recently published article, de la Pena and
Cabrita (19) reported a case of pulpitis developing in a
tooth treated by Cvek pulpotomy 7 years after treatment.
They concluded that the possible causes of this rather late
pulpal inflammation were not clear, but marginal leakage
around the coronal restoration was a likely cause. In the
present case, a double seal of glass ionomer and composite
resin was successfully used for producing an optimal coro-
nal seal. The problem with using composite resin is crown
discoloration. The function of a porcelain crown, from an
aesthetic and mechanical point of view, is superior to a
composite, but it is contra-indicated in a child of age of 8
years, with an immature dental and periodontal system.
In addition, composite crowns can be easily repaired,
reconditioned or even replaced. Composite crown cost is
minor and never rules out the use of porcelain crowns
being placed in the future (20). In this case, tooth crowns
did not have sufficient sound supporting tooth structures
(owing to crown fracture) to withstand the masticatory
and future traumatic forces occurring over the lifetime of
the teeth; however, even after 11 years, the teeth still had
their composite restorations and the patient attended the
dental office because of tooth discoloration. At this time,
root canal therapy may be indicated because of a need for
post and core restorations.
The prognosis for complicated crown fractures is good:
pulp survival following pulpotomy varies between 75%
(15) to 100% in incisor teeth (9). Some reports indicate
the need for root canal treatment after apical closure in
cases that have been treated by vital pulp therapy because
of possible necrosis, continued calcification, or internal
resorption after pulpotomy (4–6). However, others claim
histological data are insufficient to provide sufficient evi-
dence for recommending root canal treatment after partial
pulpotomy (7–9). Robertson et al. in their research study
concluded that isolated crown fracture (with or without
pulp exposure) is rarely followed by canal obliteration or
pulp necrosis (21).
Evidence of PCO by calcific tissue is often taken as a sign
of pulp degeneration. Lumen reduction can be seen years
after trauma and treatment, but such calcification is not an
indication of pulp necrosis, rather it is evidence of contin-
ued pulp function. It has been emphasised that the deci-
sion to intervene endodontically in cases of apparent pulp
space calcification should be based on evidence of pulp
necrosis/infection and not pulp calcification (2,3).
77
Apexogenesis after pulpotomy
In the present case, one of the teeth displayed PCO;
however, the patient was symptom free and no sign of
either radiographic pathologic changes or resorption could
be observed. Accordingly, no endodontic treatment was
recommended.
The time taken for apexogenesis after pulpotomy ranges
between 1 to 2 years, depending primarily upon the
extent of root development at the time of pulpotomy
procedure. The patient should be recalled at a minimum of
3-month intervals after apexogenesis therapy in order to
determine the vitality of the pulp and the extent of apical
maturation. An absence of symptoms does not necessarily
reflect the true state of the pulp. In evaluating pulpoto-
mies, clinical signs and symptoms including spontaneous
pain, swelling, discomfort on percussion and palpation,
sinus tract formation and radiographic signs of pulpal and
periapical pathologic changes are the major means of indi-
cating the state of the pulp (3). In this case, a 6-month fol-
low up showed continued root development and 11 years
later the teeth were still comfortable and free of signs of
pulpal inflammation or necrosis.
In conclusion, this case shows that vital pulp therapy
can be a successful long-term treatment and a tooth that
has been treated by vital pulp therapy may not necessarily
need root canal treatment.
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© 2006 The Authors
Journal compilation © 2006 Australian Society of Endodontology