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Summary

Pulpotomy is the operation carried out to form a neoformative dentin layer on the root section sur-face following the removal of uninfected pulp at the coronal section. The root section of the pulp canstay vital after a successful treatment. In this case, a pulpotomy treatment was performed for ortho-dontic purpose on the canine tooth with twinning tooth structure of a patient with number andshape anomalies on the upper jaw. The patient was controlled by clinical and radiographical exam-inations every 6 months, for 8 years. As the vitality tests were positive, no pathological findings havebeen observed either clinically or radiologically.Key words: pulpotomy (partial pulpectomy), apexogenesis.

Introduction

Pulp tissue may be injured due to variousreasons such as mechanical, thermal, chemicalor bacterial factors. Some reversible or irre-versible damages may be formed in the pulpwith respect to the type, severity and duration ofthe factor. In general, pulp tissue tries to consti-tute reparation of dentin in the changes consid-ered reversible. The main goal in the treatmentof dental diseases is to conserve the pulp vitality.Therefore, many researchers studied vital pulptreatment [1-6]. In order to have successfulresults from the vital pulp treatment, the indica-tions should be determined carefully. The vitalpulp treatment has numerous indications, includ-ing orthodontic and prosthetic indications.

The effect of calcium hydroxide afterpulpotomy may be the result of slight chemicalinjury, which is limited by a zone of firm necro-sis against the vital pulp tissue and the tolerationof calcium ions by the tissue. Schröder [7] pos-tulated that firm necrosis causes slight irritationand stimulates the pulp to defend and repairitself. The mineralization of the collagen startswith dystrophic calcification of both the zone offirm necrosis and degenerated cells in the adja-cent tissue [7].

Case report

A 14-year-old girl was referred to our endodonticsclinic in 1993. Clinical and radiographic exami-nation revealed that there were number and for-mation anomalies in maxillary teeth. The perma-nent lateral incisors were deficient and there wastwin teeth formation (twinning) on the patient'sleft upper canine (Figure 1). Radiographic viewof this tooth revealed that the tooth had only onesingle large canal and its apexification was incom-plete (Figure 2).

An orthodontic treatment was planned inorder to align the teeth with anomaly into thenormal position in the arch. A pulpotomy wasalso indicated, because the incision of the twin-ning was required, there was a possibility of alarge perforation area with this procedure andthere was incomplete apexification.

Following local anesthesia, the teeth wereisolated with a rubber dam. The pulp cavity wasevacuated and the surface of the pulp was irri-gated gently with isotonic saline until bleedingceased. After hemostasis, a pulpal medicament(calcium hydroxide-Merk, Darmstadt, Germany)was applied to the wound surface. Dry, sterilecotton pellets were used carefully with mildpressure to adapt the medicament to the prepared

Pulpotomy and apexogenesis (case report)

Hesna Sazak, Yildiz GaripIstanbul, Turkey

VVAARRIIAA

cavity and to remove excess water from thepaste. The remaining coronal cavity was thenrestored with a material that provided a long-termhermetic seal. It is critical to avoid bacterial con-tamination to the pulp tissue during the proce-dures and to avoid any subsequent leakage fol-lowing restoration (Figure 3). Over a week fol-lowing this procedure, the patient reported a mildsensitivity. The patient's complaints disappearedsubsequently. After 6 months, clinical and radi-ographical examinations revealed that there was

no pain, the vitality test was positive, the periapi-cal and periradicular regions were normal, apexi-fication was completed, and formation of a dentinbridge was apparent (Figure 4).

Afterwards, the patient was followed every6 months for 8 years (Figures 5, 6). In routinecontrols, it was found that the natural color andthe translucency of the tooth were maintained(Figure 7), and there was no pathological finding.

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Figure 1. Anterior view of the maxillary twinnedleft canine

Figure 4. Postoperative radiograph of the toothafter 6 months

Figure 2. Preoperative radiograph of the twinnedtooth

Figure 5. Postoperative radiograph of the toothafter 1 year

Figure 3. Postoperative radiograph of the toothFigure 6. Postoperative radiograph of the toothafter 8 year

Discussion

The main advantages of the vital pulp treatmentsare as follows: conservation of tooth vitality, norequirement of root canal therapy, and the main-tenance of the natural color and translucency ofthe tooth.

In addition to having the same indicationsalong with other vital pulp treatments, pulpoto-my is a treatment method performed when theperforation area is very large and the tooth apexis not closed yet. Although a lot of substances areused in these treatments, Ca(OH)2 is the sub-stance most commonly used. When the products

including Ca(OH)2 are applied to the pulpdirectly, caustic effects arise due to alkaline pH,and they inhibit the enzymes. Necrosis areacaused by calcium hydroxide leads the mes-enchymal cells to turn into fibroblasts first, andthen into odontoblasts that would form thematrix [1,5,6,7]. Calcium ions play an importantrole in cell proliferation, blood coagulation andmineralization. A new tissue, which resemblesdentin, is formed by the precipitation of circulat-ing calcium ions to the matrix that is composedof mucopolisaccharides and glicoproteins [4].When the regenerative tissue was examined his-tologically, it was determined that this was astructure similar to dentin and included canalswhich were more irregular and atubular at thecoronal side and irregular at the pulp side [8,9].In this current case, it was observed that thedentin layer formation was considerably thick.

In studies regarding this subject, the protec-tion of the vitality of the tooth, the maintenanceof natural color and translucency, and the factthat there was no pathologic finding on clinicaland radiographic examinations were specified assuccess criteria [3,10,11,12]. In the present case,the facts that the findings were positive and therewas no pathological finding after 8 years wereconsidered successful as well.

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Figure 7. Anterior view of the tooth during theorthodontic treatment

References

1. Sela J., Ulmansky M. Reaction of normalinflamed dental pulp to calxyl and zinc oxideand eugenol in rots. Oral Surgery, Oral Medicineand Oral Pathology, 1970; 30: 425-430.2. McWalter G.M., El Kafrawy A.H., MitchellD.F. () Pulp capping in monkeys with a calciumhydroxide compound, an antibiotic and polycar-boxylate cement. Oral Surgery, Oral Medicineand Oral Pathology, 1973; 36: 90-100.3. Tronstad L. Reactions of the exposed pulp todycall treatment. Oral Surgery, Oral Medicineand Oral Pathology, 1974: 38: 945-953.4. Shubich I., Miklos F.L., Rapp R., Draw F.S.() Release of calcium ions from pulp capping.Journal of Endodontics, 1978: 4: 342-344.

5. Ford T.R.P. Pulpal response to calciumhydroxide material for capping exposures. OralSurgery, Oral Medicine and Oral Pathology,1985: 59: 194-197.6. Stanley H.R. Pulp capping conserving the den-tal pulp. Can it be done? Is it worth? Oral Surgery,Oral Medicine and Oral Pathology, 1989; 68:628-639.7. Schröder U. Effects of calcium hydroxide-containing pulp capping agents on pulp cellmigration, proliferation and differention.Journal of Dental Res, 1985; 64: 541-548.8. Percira V.C., Bramonte C.M., Berbert A. andMondelli J., Paulo S. Effect of calcium hydroxidein powder or in paste form on pulp capping proce-dures: Histopathologic and radiographic in dog'spulp. Oral Surgery, Oral Medicine and OralPathology, 1980; 50: 176-186.

9. Sazak H., Günday M., Alatli C. Effect of cal-cium hydroxide and combination s of Ledermixand calcium hydroxide on inflamed pulp in dogteeth. Journal of Endodontics, 1996; 22: 447-449.10. Barker B.C.W., Lockett B.C. An unusualresponse by dog pulp to calcium hydroxide. OralSurgery, Oral Medicine and Oral Pathology,1971; 32: 785-794.

11. Santini A.H. Intraoral comparison of calciumhydroxide (Calnex) alone and in combinationwith Ledermix in first permanent mandibularmolars using two direct inspection criteria.Journal of Dentistry, 1985; 13: 52-59.12. Santini A.H. Long term clinical assessment ofpulpotomies with calcium hydroxide containingLedermix in human permanent premolars andmolars. Acta. Odontol Pediat, 1986; 7: 45-50.

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Correspondence to: Assoc. Prof. Dr. Hesna Sazak, DDS, PhD. Marmara Üniversitesi, Diº Hekimligi Fak.,Büyük Çiftlik sok. No.6, 80200 Niºantaºi-Istanbul, Turkey.

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