Vital pulp therapy (VPT) is intended to preserve the
vitality of the coronal or remaining radicular pulp in reversible pulp injury.
It is a reasonable treatment for immature permanent teeth after a traumatic
pulp exposure because they have great repair potential. In fact, in accordance
with the International Association of Dental Traumatology (IADT) and the
American Academy of Pediatric Dentistry (AAPD), every effort must be made to
preserve pulp vitality in the immature permanent tooth to guarantee continuous
root development, apical closure and increased strength of root walls [3]. In
the context of an immature permanent tooth with complicated crown fracture, VPT
includes procedures such as direct pulp capping, partial or cervical pulpotomy.
Direct pulp capping (DPC) is defined as the use of dental materials as a pulp
dressing to preserve the tooth vitality after a pulp exposure [4]. In the case
of complicated crown fracture, direct pulp capping is indicated only when there
is minimal pulp exposure and treatment can be performed in a short amount of
time after the injury. Partial pulpotomy was defined by Cvek as the partial
removal of the potentially inflamed and irreversibly damaged coronal pulp
adjacent to the exposure [5]. This form of treatment is particularly indicated
if a wide area of the pulp is exposed and primary care cannot be administered
within the first 2h after the injury [2]. The indication for a partial
pulpotomy is judged by the clinical evaluation of bleeding from the pulp
chamber, which should be controlled within 3 to 5 minutes under the slight
pressure of a cotton pellet soaked in physiologic saline. If bleeding is
excessive, a more invasive treatment such a cervical pulpotomy may be needed
[2]. Some authors still recommend pulpotomy as more reliable than direct pulp
capping. In accordance with the study, carried out on 375 immature permanent
teeth with complicated crown fracture, the success rates of pulp treatments
oscillate between 54.5 and 81.5% for direct pulp capping, 94 and 96% for partial
pulpotomy, and between 86 and 92% for coronal pulpotomy [6]. Furthermore, he
reported that there was no difference between partial and coronal pulpotomy.
The pulp necrosis risk was not significantly different between pulpotomy
(partial and coronal) and retreatment by pulpotomy (partial or coronal) after
direct pulp capping. However, the frequency of pulp necrosis and infection
after pulpotomy was significantly less than that with direct pulp capping using
Dycal [6]. In one hand, these results can be due to the capping material which
may occupy some parts of dentine and perhaps even enamel, thus reducing the
restoration abilityto prevent bacteria entering the tooth. Or in pulpotomy
treatments, the pulp capping material can submerged reducing thus the risk of
bacterial penetration and pulp contamination. In the other hand, the high rate
of pulp necrosis is explained by the potentially contaminated pulp tissues not
removed in case of direct pulp capping [7]. Furthermore, the long-term success
of direct pulp capping and pulpotomy is intimately linked to the type of
capping materials which are available in various kinds. In fact, according to a
study released in vitro by Youssef et al., Mineral trioxide aggregate (MTA),
Biodentine, CEM (calcium-enriched mixture) and EMD (Enamel Matrix Derivative)
exhibit similar attributes and may better results than calcium hydroxide.
Emdogain can be an interesting alternative to MTA and Biodentine in improving
pulp repair capacity following dental pulp injury [8]. Although success rates
of both partial and cervical pulpotomy are evident, partial pulpotomy remains
more reliable in traumatic exposure of the pulp. An update review of literature
carried out revealed that the cell-rich coronal pulp preserved during partial
pulpotomy aids the pulp defence reaction to resist to bacterial contamination
and provides a better healing potential. Also, partial pulpotomy maintains
dentin physiologic apposition in the cervical region, natural color and
translucency of the tooth. This procedure preserves the possibility to perform
vitality testing [9,10]. The International Association of Dental Traumatology
(IADT) guidelines 2020 have recommended pulp capping, partial or cervical
pulpotomy for the treatment of teeth with complicated crown fracture without
indication of the type of treatment [3]. The amount of time elapsed between
dental injury and treatment is not a very interesting factor to choose the
treatment procedure for the traumatic exposed pulp. In fact, the contamination
risk and the infection depth through the exposed area is increased by the
elapsed time. During the first 24 hours after traumatic exposure of the pulp,
the inflammation is limited to the superficial layers of the pulp. After this
period, inflammation spreads apically [11]. However, Cvek and Lundberg
demonstrated that inflammatory pulpal changes are confined to the uppermost 2mm
even after a period up to168 hours [12]. The results were confirmed by the
study of Heide who reported that partial pulpotomy with the extirpation of 2mm
of pulp tissue in the coronal region can be successful even after many days
[13]. Although animal studies reveal that direct pulp capping can offer
excellent prospects for success as much as 24h after exposure of the pulp to
the oral environment, it seems recommended to restrict the time limit for
direct capping to 2 h [14-16]. The level of root development at time of injury
affect the outcome of conservative pulp treatments in the case of complicated
crown fractures with concomitant luxation injuries [17]. In accordance with the
study, the pulp necrosis incidence in mature teeth was considerably higher than
with immature teeth. In fact, young teeth with open apices have a great repair
potential and better pulp prognosis than those with mature roots, because the
pulp of older patients is more fibrotic and has reduced ability to restor. In
some studies, authors state that the traumatic pulp exposure size has
relatively less influence on the prognosis [18,19]. Instead, some other authors
reported that the extent of the exposure can be a determining factor when
deciding between performing pulp capping and pulpotomy [20]. In fact, direct
pulp capping is recommended only for cases with pin point exposures in
fractured permanent teeth treated within a few hours after the dental trauma.
When the trauma involves extensive complicated fracture, pulpotomy seems rather
indicated. However, the outcome does not appear to be affected by the size of
exposure as long it is less than 4 mm. In other studies, the presence of
additional luxation injuries is judged as an important factor in the treatment
decision process for complicated crown fractures. In fact, it has been
indicated that subluxation or luxation injures may cause harm to the blood and
nerve supply entering the apical foramen, thus compromising pulp healing and
facilitating the pulp necrosis [21].
