Pulpotomy

PULPOTOMY IN PRIMARY TEETH

1. PULPOTOMY BY- Dr. SUMEET VINCENT TIGGA (G.D.C RAIPUR)

2. DEFINATION-: PULPOTOMY CAN BE DEFINED AS THE COMPLETE REMOVAL OF CORONAL PORTION OF THE DENTAL PULP , FOLLOWED BY PLACEMENT OF SUITABLE DRESSING OR MEDICAMENT THAT WILL PROMOTE HEALING & PRESERVE VITALITY OF THE TOOTH (Finn,1985 )

3. INDICATION-: Cariously exposed primary teeth, when their retention is more advantageous than extraction. Vital tooth with healthy periodontium Pain, if present not spontaneous nor persists after removal of the stimulus Tooth which is restorable Tooth with-2/3rd root length Hemorrhage from the amputation site is pale red & easy to control In mixed dentition stage primary tooth is preferable to a space maintainer

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5. CONTRAINDICATION -: Evidence of internal resorption Presence of inter radicular bone loss Abscess , fistula in relation to teeth Radiographic sign of calcific globules in pulp chamber Caries penetrating the floor of pulp chamber Tooth close to natural exfoliation

6. CLASSIFICATION-: I.Vital Pulpotomy techniques 1. DEVITALIZATION: (mummification & cauterization) Single Sitting: 1. Formocresol 2. Electrosurgery 3. Laser Two sittting : 1. Gysi triopaste 2. Easlick’s formaldehyde 3. Paraform devitalising paste

7. . 2.PRESERVATION: 1.Glutaraldehyde 2.Ferric sulphate 3.MTA 3.REGENERATION: (inductive & reparative) 1.Bone morphogenic protein II. Non-Vital pulpotomy techniques(mortal pulpotomy ) 1.Beechwood cresol 2.formocresol

8. TREATMENT OBJECTIVES- : > Amputate the infected coronal pulp, >Neutralize any residual infectious process, >Preserve the vitality of the radicular pulp. >Avoid breakdown of periradicular area >Treat remaining pulp with medicament >Avoid dystrophic pulpal changes

9. A. DEVITALIZATION ( SINGLE SITTING ) FORMOCRESOL PULPOTOMY TECHNIQUE First advocated by SWEET(1930) FORMOCRESOL SOLUTION: *19% formaldehyde *35% cresol *15% glycerine ( veichle ) Buckley’s solution: 1:5 conc. Of formocresol solution.

10. .. To prepare a 1:5 conc. Of this formula- First thoroughly mix 3 part of glycerinre with 1 part of distilled water Then add 4 parts of this preparation to 1 part Buckley’s formocresol & thoroughly mix again Mechanism Of Action: Formocresol prevents tissue autolysis by bonding to protein. This is reversible process and is accomplished without changing the basic overall structure of the protein molecules

11. Technique for Pulptomy of the Primary Teeth 1. Profound anaesthesia for tooth and tissue. 2. Isolate the tooth to be treated with a rubber dam. 3. Excavate all caries. 4. Remove the dentin roof of the pulp chamber. 5. Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round bur or sharp spoon excavator

12. . 6. Achieve heamostasis with moist cotton pellets under pressure. 7. Apply diluted formocresol to pulp on cotton pellet for 3- 5 minutes. Pressure on pellet. 9. Pulp chamber is dried with new cotton pellets . 10. Place a thick paste of ZOE in contact with pulp stumps. 11. Place stainless steel crown (or bonded composite)

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16. DEVITALIZATION PULPOTOMY( TWO STAGE ) ~Two stage procedure involves use of paraformaldehyde to fix the entire coronal & radicular pulp tissue. ~The medicaments used in this technique have a devitalizing, mummifying and bactericidal action. Indications : .Profuse bleeding .Difficulty in controlling bleeding .Spontaneous pain .Slight purulence discharge .Thickened PDL

17. ` Contraindication: .Non restorable .Necrotic .Soon to be exfoliated Formula of each agent used are as follows: 1.GYSI TRIOPASTE FORMULA : * tricresol 10 ml *cresol 20 ml * glyserine 4 ml * paraformaldehyde 20 ml *zinc oxide 60 gm

18. . 2.EASLICK’S PARAFORMALDEHYDE FORMULA: * paraformaldehyde 1 gm *procaine base 0.03 gm *powdered asbestos 0.05 gm *petroleum jelly 125 gm * carimine to colour 3.PARAFORM DEVITALIZING PASTE: * paraformaldehyde 1gm * lignocaine 0.06 gm *propylene glycol 0.05 ml * carbowax 1500 1.30 gm *carmine to colour

19. . First appointment: Isolation of the affected teeth with rubber dam Preparation of the cavity , excavate the caries On excavation of deep caries pulp exposure is encountered , ensure that the exposed site is free of debris Enlarge the cavity with round bur Cotton pellet with paraformaldehyde is placed in the exposure site ,seal it for 1 to 2 weeks (formaldehyde gas liberated from the paraformaldehyde permeates through the coronal & radicular pulp, fixing the

20. . Second appointment In the second appointment pulpotomy is carried with the help of L.A. The roof of the pulp chamber is removed and cleaned with saline and dried with cotton pellet The pulp chamber is then filled with antiseptic paste and the tooth is restored.

21. PARTIAL PULPOTOMY   T he partial pulpotomy for traumatic exposures is a procedure in which the inflamed pulp tissue beneath an exposure is removed to a depth of 1-3 mm to reach the deeper healthy tissue - Indicated for a vital , traumatically exposed, young permanent tooth, especially one with an incompletely formed apex. -Calcium hydroxide or MTA is used

22. OBJECTIVES FOR Ca(OH)₂ PULPOTOMY OF YOUNG PERMANANT TEETH-: Preserve radicular vitality, Maximize the opportunity for apexogenesis (apical development and closure), Enhance continual root dentin formation. .there should be no adverse clinical signs or symptoms of sensitivity, pain or swelling

23. PROPERTIES OF CALCIUM HYDROXIDE Calcific bridge formation(91% success) Germicidal activity Vital pulp remains Clinical success to be 65% Hystological success 35%

24. CLINICAL TECHNIQUE FOR THE Ca(OH)₂ PULPOTOMY 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 a large low-speed round bur or a high-speed diamond stone with a light touch.. 6. Control hemorrhage with a cotton pellet applied with pressure or a damp pellet of hydrogen peroxide

25. . 7 . Place a calcium hydroxide mixture over the radicular pulp stumps at the canal orifices and dry with a cotton pellet. 8. Place quick-setting ZOE cement or resin-reinforced glass ionomer cement over the calcium hydroxide to seal and fill the chamber.

26. PROPERTIES OF MTA (MINERAL TRIOXIDE AGGREGATE) 93% clinical success rate Better biocompatibility Better sealing ability-prevents leakage in pulpal & periapical tissues Less time needed for procedure Promotes regeneration of original pulp tissue Dentinal bridge formation is seen

27. USING MTA INSTEAD OF FORMOCRESOL FOR PULPOTOMY • In this new technique, the MTA paste is allowed to cover the dry pulp stumps (instead of formocresol ). • MTA is a powder composed of - Tricalcium silicate, -Bismuth oxide, - Dicalcium silicate, - Tricalciumaluminate , - Tetracalciumaluminoferrite , -Calcium sulfate dihydrate .

28. . The cement’s setting time is 3 to 4 hours. MTA paste is obtained by mixing MTA powder with sterile saline at a 3:1 powder/saline ratio. IRM is place over the MTA.

29. NON-VITAL PULPOTOMY Ideally, a non-vital tooth should b treated by pulpectomy or root canal filling However, pulpectomy of a primary molar may sometime be impracticable due to non-negotiable root canals and also due to limited patient co-operation. Hence, a two-stage pulpotomy technique is advocated .

30. SELECTION CRITERIA History of spontaneous pain Swelling ,redness or soreness of mucosa Tooth mobility Tenderness to percussion Radiographic evidence of root resorption

31. TCHNIQUE 1 ST APPOINTMENT - NECROTIC PULP IS REMOVED - PULP CHAMBER IS IRRIGATED WITH SALINE & DRIED WITH COTTON PELLET -RADICULAR PULP IS TREATED WITH BEACH WOOD CERSOL DIPPED COTTON PELLET -SEAL THE CAVITY WITH TEMP. CEMENT FOR 1-2 WEEKS

32. SECOND APPOINTMENT- - ISOLATE THE TOOTH REMOVE THE TEMPORARY DRESSING & PELLET CONTAINING BEECHWOOD CRESOL IF SIGN & SYMPTOMS PERSIST THEN REPEAT THE TREATMENT OR EXTRACT THE TOOTH IF NO SYMPTOMS PULP CHAMBER IS FILLED WITH ANTISEPTIC PASTE THEN IT CAN B RESTORED WITH STAINLESS STEEL CROWN