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Anterior teeth trauma - 14 years old female- Courtesy ROOTS

The opinions and photographs within this web page are not ours. Authors have been credited
for the individual posts where they are -
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 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 formocresol. 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, USA. 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 option. 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! - Liviu Well done 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 restorations. (L) At a later age as the young lady was just below 14 years. - Liviu Amazing case! 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 histologically. 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 inflammation. 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 these variables. 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, 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 symptoms. 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

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