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CASE REPORT
Year : 2023 | Volume
: 50
| Issue : 1 | Page : 111-117
Successful rehabilitation of traumatized immature teeth by different vital pulp therapies in pediatric patients: A case series and literature review
Mohammad Kamran Khan
Private Pediatric Dental Practice, Aligarh, Uttar Pradesh, India
Correspondence Address:
Mohammad Kamran Khan
Hamdard Nagar-A, Civil Line, Aligarh, Uttar Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jss.jss_138_22
Conservative treatment of the traumatized immature vital permanent teeth is considered critical step for rehabilitating with continued normal development of root and apex closure without adverse sequelae. Hence, the present article describes the case series of successfully and effectively managing the fractured vital immature permanent teeth (Ellis Class-II and Ellis Class-III dental trauma) in pediatric patients by employing three different conservative Vital Pulp Therapy (VPT) approaches using suitable sealing/pulp-capping agents to promote apexogenesis, followed by functional and esthetic restoration. In all the three presented cases, Apexogenesis was achieved without any unfavorable outcome like pulpal or periapical sequelae. Furthermore, the current dental literature relevant to VPT procedures for apexogenesis in young permanent teeth has been thoroughly described in this article.
Keywords: Apexogenesis, conservative endodontic treatment, Cvek pulpotomy, dental rehabilitation, dentinal sealing, immature permanent teeth, mineral trioxide partial pulpotomy, open apex, pediatric endodontics, vital pulp therapy
Oral health is considered essential for normal growth, nutrition, and quality of life.[1] However, the increased prevalence of traumatic dental injuries (TDIs) has become a public health concern worldwide.[2],[3],[4] TDIs are mostly found in the first and second decades of life.[2],[3] TDIs occur more frequently in growing age group including children and adolescents.[4] TDIs adversely influence the functions and esthetics of teeth that leads to physical and psychosocial problems in affected individuals.[1] Among different types of TDIs, majority of them are the crown fractures (26.2%–44.1%) that may be either complicated or uncomplicated depending on pulp exposure.[2],[3]
Dental treatment of TDIs in permanent teeth is considered complex and difficult owing to its multiple factors. Since, root growth and apical closure of permanent teeth take about 3 years to complete after eruption into the oral cavity. When immature (young) teeth with open apex sustain trauma injury, normal root development may be halted when timely and appropriate treatment is not provided. Consequently, short roots, open root apex, thin root dentin walls, the abnormal crown-to-root ratio, increased mobility of the traumatized tooth, and difficulty in obturation of the root canals are encountered.[2],[3]
Different treatment approaches for addressing the traumatized vital immature teeth have been suggested in the dental literature. Various vital pulp therapy (VPT) modalities have both advantages and disadvantages owing to the inherent attributes of each technique and pulp-capping material.[2],[3]
In the existing literature, there is scarcity of articles demonstrating the full rehabilitation of traumatized vital immature permanent teeth by promoting apexogenesis with different vital pulp therapy (VPT) procedures using different pulp-capping/dressing materials. Hence, the present article describes the case series on successfully and effectively managing the fractured vital immature permanent teeth in pediatric patients by employing three different conservative VPT approaches using suitable sealing/pulp-capping agent, followed by functional and esthetic restoration. In follow-ups, patient was clinically and radiographically evaluated for 9 months with 3-month intervals. In the all three presented cases, apexogenesis was achieved without adverse pulpal or periapical sequelae. Furthermore, the current dental literature relevant to VPT procedures for apexogenesis in young permanent teeth has been thoroughly described in this article. The manuscript of this case series article has been prepared in accordance with CARE checklist case reporting guidelines.
Clinical Case ReportsCase 1: VPT by sealing the fractured dentinal surface
A 9-year-old boy presented with sensitivity to cold food in the broken upper front tooth. In dental history, dental trauma event i.r.t tooth 21 due to playing activities at home 2 days back was revealed. No history of spontaneous pain or swelling in relation to fractured tooth 21 was revealed. Medical history was insignificant. On general examination, the patient was found systemically healthy. Dental examination revealed the Ellis Class-II fracture of tooth 21 [Figure 1]a. There was no abnormal mobility and pain on palpation present in respect to tooth 21. Oral mucosa and gingiva were found apparently normal i.r.t tooth 21. On radiographic evaluation, tooth 21 with open apex (Cvek stage 4) was observed [Figure 1]b. Pulp sensibility tests (thermal and electric pulp tests) revealed a healthy condition of the pulp of 21. The patient displayed cooperative behavior (Frankl behavior rating scale: 3 [positive]).
Figure 1: Preoperative images of the “case-01” showing (a) fractured permanent maxillary right central incisor with Ellis Class-II dental injury; (b) IOPA radiograph depicting the immature root with open apex of the fractured tooth #21On the basis of dental trauma history and clinical and radiographic examination findings, the clinical diagnosis of reversible pulpitis was associated with Ellis Class-II fracture of tooth 21 with open apex. The appropriate treatment plan was determined consisting of vital pulp therapy procedure to promote apexogenesis, followed by definitive esthetic restoration with long-term follow-up evaluations. The clinical diagnosis and appropriate treatment plan were explained to the patient's parent, and thus, written informed consent was obtained.
The vital pulp therapy was performed such that the fractured dentinal surface of the crown of tooth #21 was sealed by a thin layer of resin-modified glass ionomer cement (RMGIC) material (3M ESPE Vitrebond™ Light-Cure Glass Ionomer) to occlude the open dentinal tubules and prevent irritation/infection of the underlying pulp and also to provide relief from dentinal hypersensitivity [Figure 2]a. The entire procedure was performed under aseptic conditions. Patient was advised for periodic follow-up visits. In follow-up with 3-month interval, the patient was found asymptomatic with a continued normal apexogenesis process with apical closure [Figure 2]b, [Figure 2]c, [Figure 2]d. Pulp was found normal on pulp sensibility tests at each follow-up visit. Subsequently, the functional and esthetic rehabilitation of tooth #21 [Figure 2]e and [Figure 2]f was accomplished with direct composite restoration (Filtek™ Z250 XT Nano Hybrid Universal Restorative Composite, 3M ESPE™). Patient and his parent displayed high satisfaction to the rendered treatment.
Figure 2: Intraoperative images (a) and (b) showing the application of thin layer (seal) of resin-modified GIC over the exposed dentinal surface of fractured crown of tooth #21; Follow-up images (c) after 3 months; (d) after 6 months showing the successful progression of the normal apexogenesis in the tooth #21; (e) and (f) functional and esthetic rehabilitation with direct composite restoration. GIC = Glass ionomer cementCase 2: VPT with Cvek partial pulpotomy using calcium hydroxide
A 9-year-old boy presented with fractured upper front tooth. Dental history revealed a traumatic injury to tooth 21 due to fall over stairs at home 1 week ago. There was no history of spontaneous pain and swelling i.r.t. tooth 21. Medical history was noncontributory. On general physical examination, the patient was found systemically healthy. Extraoral examination finding was normal. On intraoral examination, Ellis Class-III dental trauma with pinpoint exposure (~1 mm) in tooth 21 was observed [Figure 3]a and [Figure 3]b. There was no clinically abnormal mobility and sensitivity/pain on palpation and percussion test. Oral soft tissues were in a healthy state. Pulp sensibility tests revealed the positive response. On radiographic examination, fractured tooth 21 was found with immature root and open apex (Cvek stage 4) [Figure 3]c. Furthermore, the periapical region was normal in respect to tooth 21. Patient was found cooperative (Frankl behavior rating scale: 3 [positive]).
Figure 3: Preoperative images of the “case-02” showing (a) Ellis Class-III dental injury in tooth #21; (b) Pinpoint pulp exposure; (c) preoperative IOPA radiograph depicting the immature root with open apex w.r.t. tooth #21; intraoperative images showing the (d and e) Cvek pulpotomy procedure with calcium hydroxide performed under rubber dam; (f) calcium hydroxide was applied over the pulp stump and was sealed with RMGIC. RMGIC = Resin-modified glass ionomer cement, IOPA = Intra-oral Peri-apicalBased on the patient's dental trauma history and clinical and radiographic evaluation, the clinical diagnosis of Ellis Class-III dental injury in relation to immature vital permanent tooth 21 was determined. Accordingly, an appropriate treatment plan was made for treating the affected tooth to promote apexogenesis by employing the vital pulp therapy approach followed by esthetic restoration. The clinical diagnosis and treatment options were discussed with the patient's parent, and thus, the informed consent was obtained.
Partial pulpotomy (Cvek pulpotomy) was employed as vital pulp therapy modality in this case. The whole procedure was carried out under standard aseptic conditions and minimally invasive approach to preserve the underlying pulp vitality [Figure 3]d. About 2-mm superficial pulp tissue was extirpated judiciously using the sterile spoon excavator. Pulpal hemorrhage was controlled within 3.5 min by applying a gentle pressure with dampened cotton soaked with 2.5% sodium hypochlorite [Figure 3]e. Irrigation was done judiciously with a normal saline solution. The calcium hydroxide (Ca(OH)2) paste (Dycal™ Dentsply) was used for dressing the amputated pulp [Figure 3]f. The Ca(OH)2 paste was condensed appropriately to adapt over the pulpal surface completely [Figure 3]f. The walls of the pulpal cavity were cleaned with dampened cotton pellets. Subsequently, the Ca(OH)2 dressing was sealed by RMGIC (3M ESPE Vitrebond™ Light-cure glass ionomer). Patient was kept on periodic follow-up for clinical and radiographic evaluation and also for coronal seal evaluation. After follow-ups with 3-month interval, the affected tooth # 21 was found with favorable outcomes in terms of root development and apical closure, i.e., apexogenesis and coronal seal were found intact [Figure 4]a, [Figure 4]b, [Figure 4]c. Pulp was found normal and vital on pulp sensibility tests at each follow-up visit. The fractured coronal structure was reconstructed with composite material (Filtek™ Z250 XT Nano Hybrid Universal Restorative Composite, 3M ESPE™) for superior strength and esthetics [Figure 4]d. The periapical region was normal radiographically. Patient and his parent displayed satisfaction on achieving the successful treatment outcomes.
Figure 4: Follow-up images (a) after 3 months; (b) after 6 months showing the intact coronal seal (c) with favorable clinical signs and symptoms of continued apexogenesis in tooth#21; (d) functional and esthetic rehabilitation of the crown with direct composite restorationCase 3: VPT with partial pulpotomy using mineral trioxide
An 8.5-year-old boy presented with broken upper front tooth. Dental history revealed the traumatic injury to tooth 11 due to collision with door at home one day back. Medical history was unremarkable. General physical examination revealed the normal systemic health. On intraoral examination, Ellis Class-III fracture of tooth #11 was seen [Figure 5]a. Slight oozing of blood was seen from gingival sulcus of tooth 11, but no abnormal mobility and sensitivity were present on palpation and percussion test. On radiographic examination [Figure 5]b, fractured tooth 21 was found with immature root and open apex (Cvek stage 4). Patient was cooperative (Frankl behavior rating scale: 3 [positive]).
Figure 5: Preoperative clinical image of “case-03” showing (a) Ellis-Class-III fracture w.r.t. tooth #11; (b) Preoperative radiograph showing immature root with open apex of 11; (c-f) Intraoperative clinical images of partial pulpotomy procedure with MTA under rubber dam; (g-i) follow-up clinical and radiographic images showing the successful apexogenesis occurring in tooth #11; (j) functional and esthetic rehabilitation of the crown with direct composite restoration. MTA = Mineral trioxideConsidering the patient's dental trauma history and clinical and radiographic evaluation findings, the clinical diagnosis of Ellis Class-III of tooth 11 with immature root and apex was established. The treatment plan consisting of employing the vital pulp therapy approach with partial pulpotomy using mineral trioxide (MTA) (ProRoot™ MTA, Dentsply) followed by coronal structure rehabilitation with direct composite restoration was determined. Patient and his parent were informed regarding the diagnosis and suitable treatment options. After explaining the diagnosis and suitable treatment options to the patient's parent, the written informed consent was obtained.
Partial pulpotomy using MTA was performed under rubber dam isolation. About 2.5 mm depth of inflamed pulp tissue was extirpated to reach the underlying healthy pulp; the entire procedure was performed under aseptic condition with minimally traumatic-endodontic approach [Figure 5]c, [Figure 5]d, [Figure 5]e. Pulpal hemorrhage was controlled readily using cotton pellet soaked in sodium hypochlorite [Figure 5]e. MTA was placed and adapted adequately over the amputated pulp surface [Figure 5]f. The cavity walls were cleaned, and then, wet cotton pellet was placed over the MTA plug (ProRoot™ MTA, Dentsply). Subsequently, the access cavity was coronally sealed with RMGIC adhesive material (3M ESPE Vitrebond™ Light-Cure Glass Ionomer) [Figure 5]g, [Figure 5]h, [Figure 5]i. Patient was instructed to care treated tooth at home and maintain meticulous oral hygiene and was advised for periodic follow-up. At 3- and 6-month follow-ups evaluation, patient was found asymptomatic and was observed with favorable outcomes of provided treatment such as continued normal root development and apical closure, i.e., apexogenesis without any adverse sequela [Figure 5]g, [Figure 5]h, [Figure 5]i. Later, fractured coronal structure was reestablished by direct composite restoration (3M ESPE Filtek™ Z250 XT composite resin) [Figure 5]j. Patient revealed satisfaction with rehabilitation of the tooth 11 [Figure 5]j.
DiscussionTraumatic injuries of permanent teeth strongly influence the oral health-related quality of life (OHRQoL) of children, adolescents, and their families. However, its timely and correct treatment can reestablish the functional and esthetic aspects of teeth with regain of OHRQoL.[5] However, seeking of an immediate dental treatment for TDIs is mostly neglected by affected children, parents/caregivers, and teachers.[6] Prompt dental management of such injuries can result in favorable prognosis with conservative therapeutic approaches. One such approach in dentistry is the vital pulp therapy (VPT) procedures.
VPT procedures are indicated in teeth having reversible pulpitis, mechanical exposure, or recent traumatic exposure of pulp in the absence of any periapical pathology.[7] These procedures are carried out to eliminate the local irritants (noxious stimulus/bacteria) and placement of a pulp-capping agent (protective material) directly or indirectly over the pulp tissue for preserving its vitality.[8] Immature (young) permanent teeth are usually known to have a good potential to recover after its traumatic pulp exposure, and thereby conservative pulp treatment modalities (i.e., VPT) enhance the possibilities of preserving or maintaining the vitality of pulp tissue and also to continue normal root growth and apex closure (i.e., apexogenesis).[9]
The condition of pulp tissue (vital or nonvital) and the stage of root development (complete/incompletely formed root with closed or open apex) are considered to be critical factors in determining the suitable treatment plan.[10] In addition, the time elapsed between TDI event and receiving the dental treatment is also pivotal in determining the correct therapeutic procedure as well as its prognosis.[11]
Various approaches of vital pulp therapy (VPT) for managing the immature vital permanent teeth have been recommended by the American Academy of Pediatric Dentistry (AAPD), such as protective liner, indirect pulp treatment (IPT), Direct Pulp Capping (DPC), Cvek partial pulpotomy, and conventional pulpotomy.[12] Even though VPT has been an issue of controversy regarding the diagnostic criteria, pulpal status assessment, appropriate treatment approach, and predictability of its prognosis.[13] The updated evidence-based guidelines/suggestions for managing TDIs and for selecting the appropriate treatment are regularly provided by the International Society of Dental Traumatology, American Association of Endodontists, American Association of Pediatric Dentistry (AAPD), and European Endodontic Society.
VPT procedures have been reported very successful and effective on traumatically pulp exposed teeth owing to the presence of healthy pulp, whereas teeth with cariously exposed pulp are usually not successful due to relatively less predictable outcomes of capping/medicating the inflamed/infected pulp.[14] Furthermore, in carious exposure of coronal pulp, the depth and area of inflammation are very uncertain/unpredictable, and consequently, its pulp capping may lead to failure.[15] The requisites for the successful VPT in traumatized immature vital teeth are: the noninflamed or reversibly inflamed pulpal tissue, easily controllable pulpal hemorrhage, application of biocompatible pulp-capping medicament/agent, and the creation of seal (hermetic seal).[11],[16] In the present clinical cases, all the above-mentioned prerequisites were evident and that indicated for adopting the VPT procedures such as the pulp protection/sealing of open dentinal tubules (i.e., IPT), Cvek partial pulpotomy with Ca(OH)2 and partial pulpotomy using the MTA.
Pulp protection/indirect pulp-capping procedure can be employed to treat enamel–dentin fractures without pulp exposure.[2],[11],[16],[17] In the presented case-1, pulp protection procedure/IPT approach by sealing/occluding the exposed dentinal tubules of fractured crown surface with chemically and micromechanically bonded restorative material, i.e., RMGIC, was carried out. Hence, the provided treatment with sealing of the exposed dentine was proved to be successful in achieving the favorable clinical and radiographic outcomes in follow-up evaluation such as continued normal development of root and apical closure without any unfavorable complication like pulpal necrosis, periapical involvement, root resorption, or ankylosis.
Since exposed dentinal tubules of fractured tooth surface make a portal for the invasion of oral microbes into the underlying pulp. Hence, a protective sealing agent must be applied as an immediate treatment to preserve the pulp vitality and to prevent the infection root canals. After sealing the exposed dentin surface, definitive/final restoration needs to be delivered after ensuring the pulpal and periradicular status.[18] It has been reported in existing literature that IPT/direct restoration of uncomplicated coronal fracture has good treatment prognosis in young individuals with TDI.[19],[20]
In the first case, RMGIC was used as a sealing agent for exposed dentine surface of fractured tooth 21 due to several inherent advantages/benefits of RMGIC compared to traditional glass ionomer cement (GIC) and composite resins materials as mentioned in the existing dental literature.[21] It has been reported that a definitive adhesive restoration should be placed as early as possible after the dental trauma incident. If this is not possible during the initial immediate treatment, then definitive restoration can be postponed; however, dentinal fracture (exposed dentinal tubules) should be covered/sealed meticulously to prevent the pulp insult/infection. Immediate sealing of fractured surface can be accomplished using an adhesive material like dentine-bonding agent and a layer of flowable composite resin.[11] Hence, in the case-1, the dual-cure adhesive resin-based material with chemical bonding to tooth structure attribute (RMGIC) was used to protect the pulp from noxious irritants and to relieve the dentinal hypersensitivity problem. It has been reported recently in a published article that although dentin tissue is present over the underlying pulp in uncomplicated crown fracture, pulpal disease or adverse pulpal/sequelae may develop.[22]
Partial pulpotomy procedure is usually indicated in immature tooth with open apex for a small pulpal exposure (<2 mm) that may be either mechanical/traumatic or carious in nature, where the pulpal hemorrhage is controllable in about 1–2 min. Partial pulpotomy has been found with higher successful outcomes in traumatically exposed in contrast to cariously exposed permanent teeth. Moreover, in immature teeth, such treatment approach has been found more successful among the other VPT modalities.[16]
During the initial hours of the pulp exposure, the tissue alterations have been reported to occur due to damage from the mechanical trauma and negligible/minimal superficial inflammatory changes of the underlying pulp. After 7 days of pulp exposure, the inflammatory response has been reported to be more accentuated, however does not extend >2 mm into the underlying pulp.[17] Thereby, the conditions for VPT are favorable within the initial days after dental trauma incident. Furthermore, partial pulpotomy is reported highly preferable for the cases having larger pulp exposure, and the prompt dental treatment is not rendered within initial hours following the injury event.[23] Although the dental literature is not conclusive with regard to difference in the clinical results of Cvek pulpotomy procedure in teeth having open or closed apex, it appears that teeth with open apex have much better prognosis. The Cvek pulpotomy outcomes may be compromised by a concomitant luxation type of injury that diminishes the blood supply and innervation of fractured tooth.[24] Based on the aforementioned rationale, in the case-2 and case-3, partial pulpotomy procedure was carried out using Ca(OH)2 and MTA medicament.
In partial pulpotomy method, the rinsing of the pulp (cavity) wound using the sodium hypochlorite (0.5%–5%) solution or chlorhexidine (0.2%–2%) is suggested to achieve hemostasis and disinfection of the underlying pulp.[11] Cotton pellets soaked in sodium hypochlorite can be applied over the amputated pulp surface with a gentle pressure. If the inflamed pulp is extirpated (mostly 2 mm) till an underlying healthy pulp is reached, any hemorrhage from pulp is likely to stop within 5 min. If hemostasis is not attained within this duration, then the extirpation of the whole coronal pulp (conventional pulpotomy) can be indicated as the last resort to preserve vitality of the radicular pulp to promote apexogenesis.[11]
Various hemostatic agents have been reported in the literature to use to halt the pulp bleeding and to allow subsequent capping agent/medicament to be placed in a relatively dry operative field. Sodium hypochlorite has been suggested to remove the coagulum, control hemorrhage, remove dentin chips, and aid formation of dentinal bridge. Two other important factors in predicting pulpal responses to VPT are the sealing ability and the nontoxicity of material. However, bacterial contamination is believed to be the main factor.[11] Due to the above-mentioned rationale of using sodium hypochlorite in partial pulpotomy procedure, in the presented case-2 and case-3, the cotton soaked with 2.5% NaOCl2 solution was employed judiciously.
Ca(OH)2 is the most commonly used material in pulp capping or therapy in endodontics, owing to its favorable biological and antimicrobial characteristics, such as induction of hard tissue formation, reparative dentin formation after pulp therapies of pulp exposure, and capacity to stimulate the new bone formation or healing of periradicular lesion and inhibition of external or internal root resorption.[24] Ca(OH)2 has been a gold-standard medicament/pulp-capping agent and has shown success rates in VPT procedures, despite its poor mechanical properties (disintegrates owing to its poor tensile and compressive strength) and also its relatively higher dissolution/solubility characteristics with time, relatively porous dentinal bridge (tunnel defect) that may result in microleakage or eventually reinfection of the pulp. Hence, Ca(OH)2 requires an overlying good-quality adhesive restoration with superior mechanical and sealing properties to prevent bacterial invasion of the underlying pulp.[11],[25]
MTA material has been used widely and proved to be highly successful in various dental and endodontic procedures due to its advantageous clinical properties compared to Ca(OH)2.[26] It promotes the healing and repair of pulp due to its higher biocompatibility, lower cytotoxicity, and stimulates odontoblast to form dentinal bridge barrier due to the recruitment and proliferation of undifferentiated mesenchymal cells and their differentiation to odontoblast-like cells.[26] Moreover, histologically, the newly calcified bridge generated in contact with overlying MTA is relatively thicker and with minimal pulpal inflammation in contrast to Ca(OH)2.[26] MTA has been reported in the literature to show a superior clinical performance than Ca(OH)2.[26] Even, pulpotomy using MTA in symptomatic teeth has been evaluated in previous studies and that resulted in relief of pain following pulpotomy, and histological evaluation showed the dentinal bridges formation, maintaining the vitality of pulp and also negligible or no inflammation in the pulp. However, MTA also demonstrates shortcomings such as high cost, extended setting time, poor handling properties, and the discoloration tendency.[11] MTA and its variants have reported to create a homogenous dentinal bridge compared to Ca(OH)2 and other pulp-capping agents.[27] In a recently published case report, partial pulpotomy using MTA demonstrated satisfactory outcomes similar to the currently presented case-3.[27]
Several types of pulp-capping materials/agents for VPT have been described in existing literature such as ZOE cements, polycarboxylate cements, collagen, Ca(OH)2, bonding agents, and GIC, and recently some other materials such as MTA, Biodentine, enamel matrix derivative (Emdogain), bone morphogenetic proteins, transforming growth factor-β, bioceramic, calcium-enriched mixture (CEM) cement, tricalcium phosphate cement, propolis, and EndoSequence.[16],[28] Biodentine has been reported superior to Ca(OH)2 as pulp-capping material for mechanically exposed teeth.[28]
Some previous studies suggest that the Biodentine was found to show similar effects on dentinal bridge formation as MTA does. However, a recent systematic review and meta-analysis have reported an almost similar success rates among MTA, Ca(OH)2, CEM, platelet-rich fibrin, and triple antibiotic paste as pulpotomy-dressing medicaments/agents in the treatment of young permanent teeth. Pediatric dentists may consider cost effectiveness when choosing pulpotomy-dressing agents in clinics.[29] Recently, hydraulic calcium silicate cements as pulp-capping medicaments/agents have been compared to Ca(OH)2 and was found superior in histological and clinical aspects, yet use of Ca(OH)2 is still popular among dental professionals.[30] Lasers have also been reported to be effective and successful in VPT procedures to promote apexogenesis in traumatically exposed pulp of young permanent tooth.[31]
Partial pulpotomy after dental trauma incident is reported with much higher success rates, especially in immature teeth with open apex (90%–100%); however, good success rates in mature teeth (70%–100%) have been reported in recently published comprehensive review.[25]
As age of an individual increases, several changes in pulp tissue also occur, like reduced cell density (decreased pulp cellularity), and more pronounced amount of fibrous tissue might influence and reduce the pulp's regenerative tendency. Nevertheless, VPT after trauma should not be advised/reserved/indicated for only children and adolescents, even should be considered for adult patients too.[25]
Teeth that undergo pulp preservation procedures/VPT should be periodically monitored to assess the treatment progress and outcome.[25] In all the presented cases, the follow-up has been accomplished.
One of the critical steps of successful management of fractured vital teeth is esthetic and functional rehabilitation of fractured tooth. There are several durable and esthetic restorative options available such as, biological restorative approach with reattachment of the fractured tooth fragment, composite restoration, and jacket crowns (porcelain-fused-to-metal crown and all-ceramic crowns) that must be in compliance with the growing age of patient. In the current all three cases, direct composite restoration was done.
ConclusionBased on the successful outcomes of the provided treatment in the presented three clinical cases, it can be concluded that vital pulp therapy (VPT) are the conservative therapeutic modalities for the traumatized vital permanent teeth with thin dentinal root walls and open apex. The VPT approaches should be attempted after ascertaining the diagnostic and prognostic factors related to traumatized teeth to promote apexogenesis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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