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Pulpotomy and the Stainless Steel Crown

Pulpotomy

Pulpotomy Pulpotomy refers to the surgical removal of the coronal portion of the pulp.

The most common pulp therapy procedure for vital primary teeth is pulpotomy. It is used when

the coronal pulp is inflamed but the radicular pulp is deemed to be healthy (consistent with the

diagnosis of reversible pulpitis).

These techniques involve the removal of inflamed coronal pulp tissue and the application

of a dressing to the radicular pulp in an attempt to either promote healing of, or fix, the upper

portions, and to preserve the vitality of the apical tissue. Because of the difficulties involved in

diagnosing the condition of the pulp tissue histologically before the commencement of treatment,

careful assessment must be made at each stage of the procedure. Whenever the haemorrhage

from the radicular pulp stumps is profuse and uncontrolled, the assumption is made that the

inflammatory process has extended into the radicular tissue, and the therapy modified

accordingly. There are three pulpotomy techniques(Carotte, n.d.)

Indications and contraindications of pulpotomy

Indications Contraindications
caries removal results in pulp exposure in a Swelling, fistula, pathologic mobility,

primary tooth with a normal pulp or uncontrolled haemorrhage from radicular pulp

reversible pulpitis or after a traumatic pulp

exposure
remaining radicular tissue is judged to be Internal root resorption, pathologic external

vital without suppuration, purulence, root resorption, periapical radiolucency,


necrosis, or excessive hemorrhage furcation radiolucency (Bott, 2014)
no radiographic signs of infection or

pathologic resorption (Winters, Cameron, &

Widmer, 2013)

Pulpotomy techniques and procedure

1. Vital formocresol pulpotomy

The treatment is carried out using local anaesthesia and adequate isolation. Following

cavity preparation in the normal manner, the deep caries is removed and the coronal pulp

chamber opened, such that there is no overhanging dentine inhibiting the complete removal of

the pulp tissue. The coronal tissue is removed using a large excavator or sterile rosehead bur. If a

high-speed diamond bur is used it should be cooled with sterile water or saline. Sterile cotton

wool is applied to the radicular pulp tissue to achieve haemostasis. A small pledget of cotton

wool is dipped in a 1:5 dilution of Buckley's formocresol and squeezed to remove excess liquid.

Accidental leakage of formocresol into the oral cavity can lead to a chemical burn of the mucosa

or gingiva It is placed over the radicular pulp stump for 5 minutes in order to fix the inflamed

tissue and bacteria and thus allow healing of the unaffected pulp. If the haemorrhage has

completely stopped, a layer of zinc oxideeugenol or glass-ionomer cement is applied, and the

tooth restored, preferably with a preformed stainless steel crown to prevent subsequent fracture

of the weakened tooth .

Other materials have been considered as an alternative to formocresol.4 Concerns about

the safety of formocresol led to investigations of pulpotomies employing a 2% glutaraldehyde

solution as an alternative dressing, but research has shown a lower clinical success rate than with
formocresol. Concern about hypersensitivity to and handling of glutaraldehyde have largely led

to its abandonment as a treatment alternative.

Recent work by Waterhouse et al. has shown that very favourable results have been

achieved with calcium hydroxide when it has been applied in carefully controlled

circumstances.5 Following haemostasis, calcium hydroxide powder was delivered to the pulp

chamber using a small, sterile, endodontic amalgam carrier. The powder is condensed over the

pulp stumps with an amalgam condensor and small pledgets of cotton wool. Failure of this

technique is explained by the presence of an extra-pulpal clot separating the calcium hydroxide

from the pulpal tissue and thus impairing healing.

Both the calcium content and alkaline properties of the dressing are important to achieve

healing. An initial layer of necrotic tissue develops, which becomes associated with an

inflammatory reaction. Subsequently, a matrix forms and mineralises to become a hard tissue

barrier of dentine-like material.


2. Devitalisation pulpotomy

This is a two-stage procedure, used when local anaesthesia cannot be obtained to permit

extirpation of the pulp, or when haemorrhage is uncontrolled before or following the application

of formocresol. This technique mummifies and fixes the coronal pulp tissue, whilst the major

part of the radicular pulp remains vital, but it carries a lower success rate.6

If the tooth is not anaesthetised, cavity preparation is carried out as far as possible and

access is gained to the pulpal exposure. A small amount of paraformaldehyde devitalising paste

on a pledget of cotton wool is applied to the exposed pulp tissue. Formaldehyde vapour liberated

from the dressing permeates through the pulpal space, producing fixation of the tissues. A soft

layer of zinc oxideeugenol temporary dressing is then placed, without applying pressure, to seal

the medicament in position. The child and parent must be warned of possible discomfort, for

which analgesics are recommended. After one to two weeks the tooth is checked for signs and

symptoms. The devitalised coronal pulp may now be removed, without the need for local

anaesthesia. A hard setting layer of zinc oxideeugenol, which may be mixed with formocresol,
is then placed over the radicular stumps and the tooth restored. If some vital tissue remains in the

coronal pulp chamber, a further dressing of paraformaldehyde paste is required.

3. Non-vital pulpotomy

This technique has been advocated where there is irreversible change in the radicular

pulp, or where the pulp is completely non-vital, but where pulpectomy and root canal treatment

is considered impractical. The little clinical evidence available suggests a limited prognosis of

approximately 50%. At the first visit the necrotic pulp contents are removed as before, and, using

small excavators, as much as possible of the radicular tissue. Beechwood creosote solution on a

cotton pledget is sealed into the cavity with a zinc oxideeugenol dressing.

One to two weeks later the tooth is checked for signs and symptoms. If there is evidence

of infection (sinus, pain, swelling or mobility) a further beechwood creosote dressing should be

placed. If, however, symptoms have resolved, the tooth may be restored as with the previous

pulpotomy techniques(Carotte, n.d.).


Post pulpotomy restorations

Stainless steel crown

The stainless steel crown (SSC) covers and protects the entire tooth and are very durable.

They are difficult to dislodge if placed properly, with excellent adaptation to the tooth. They

represent the preffered therapy for the primary molar teeth after pulpotomy(Berg, 2013).

Tooth preparation

A rubber dam is first placed

There are 3 basic steps to tooth preparation for SSC

1. occlusal reduction

2, buccal and lingual reduction/ beveling

3. proximal reduction

Wedges can be inserted between the teeth during the reduction process.

1. Occlusal reduction

Depth cuts are made to establish depth of occlusal reduction.

Depth cuts used to gauge preparation depth (Berg, 2013)


Occusal reduction can be done by following external contours of the tooth. However is

pulpotomy is planned, a simple reduction of the occusal aspect by removing 1-1.5mm of tooth

structure can be done.

(Berg, 2013) occusal reduction following tooth contours

Following occlusal reduction all caries should be removed. It is recommended that caries

removal should start at the periphery and progress towards the pulp. This sequence ensures that if

the pulp is exposed the operator is ensured that the tooth is not only caries free but a pulpotomy

or pulpectomy can be performed in a clean uncontaminated field. In the absence of a pulp

exposure the exposed dentin can be protected by calcium hydroxide or glass ionomer cement

(Keith Titley, n.d.)

Buccal and lingual beveling followed by removal of caries (Berg, 2013)


2. Buccal and lingual reduction/ beveling

Reduction of the entire buccal or lingual surface is not recommended, unless for very

prominent buccal bulges (in first primary molars) and the bevel step.

Large buccal bulge of primary molar reduced (Berg, 2013)

It is best to only slightly reduce the cervical bulges of some teeth just above the gingival

tissue- generally the occlusal half above the bulge of the buccal and lingual surfaces. This

reduction is generally limited to a 45- degree angled bevel of the reduced occlusal surface onto

the occlusal half of the buccal and lingual surface. Most of the time, subgingival reduction is not

necessary.

There are three approaches to this step:

a. beveling the buccal and lingual surfaces, but without overall reduction

b. beveling buccal and lingual surfaces and slightly reducing the buccal lingual surfaces to

approximately the SSC thickness

c. reduction of occlusal, buccal and lingual surfaces significantly until a trapezoid shape

preparation is formed (Berg, 2013)


(Berg, 2013) Three approaches to buccal and lingual reduction/ beveling step

It is recommended to trying the selected crown for size before carrying out any lingual or

buccal reduction (Randall, 2002)

3. Proximal reduction

Generally done after occlusal and buccal lingual reduction as it will be easier. The

adjacent teeth are ensured that they are not damaged by this procedure by correct angulation of

the bur. The common mistake of forming an interproximal ledge will interfere with seating of the

SSC. Use an explorer of bur to check very a smooth, ledge free interface.

All lines, points and angles should be rounded, and have a close morphology to that of

the original tooth. This technique will result in better SSC restoration, however be careful to

avoid loss of retention(Berg, 2013).

The burs needs to be angles so as to not damage the adjacent teeth (Berg, 2013)
Final preparation before fitting of SSC, all line and points and angle are rounded (Berg, 2013)

Crown Adaptation

A stainless steel crown of the correct mesial distal width is selected and tried on the tooth.

The crown height should be checked to ensure proper occlusion. If a preformed and precrimped

crown is being used it must be remembered that this crown can only tolerate a minimal amount

of adjustment to ensure an adequate marginal fit. It is thus the authors opinion that the

uncrimped straight sided crown is more versatile, although more time consuming, since it can be

cut and contoured to fit.

The initial trying on of the crown may indicate that it is in supra occlusion and the reason

for this may be that the occlusal reduction of the tooth was insufficient or that the crown is too

long. In the case of the former further occlusal reduction can be carried out and in the latter the

length of the crown can be reduced by using crown and bridge scissors at its gingival margin or

by the use of abrasive stones. When reducing the height of the crown an even width band of

stainless steel should be removed from its periphery. This ensures that the finished crown will

follow the gingival contour of the tooth. All cut and abraded margins should be polished.

The crown can then be adapted to fit the tooth by the selective use of pliers. A contoured

and crimped crown should be placed on the tooth by engaging the lingual surface and then
wedged over to the buccal. A well adapted crown should audibly snap into place without the

application of an excessive amount of force. The margins should be checked with an explorer to

check the marginal adaptation and appropriate adjustments made in cases of deficiency. Before

final cementation the occlusion should also be checked again.

A polycaboxylate or glass ionomer cement can be used for the crowns final cementation

and the clinician must ensure that any excess cement is removed(Keith Titley, n.d.). The string of

knotted floss if places in the interproximal area and sawed buccolingaully to remove excess

without displacement of the crown ( as upward lifting will). (Berg, 2013)Any deficiencies in the

coronal hard tissues will be made up by the cement itself so that coronal build up is not necessary

(Keith Titley, n.d.)

Stainless Steel Crown after cementation (Berg, 2013)

Inlays and onlays

Inlays and Onlays are forms of indirect restoration used when a molar or premolar is too

damaged to support a basic filling, but not so severely that it needs a crown. Inlays and Onlays

are not as extensive as crowns which cover most of the tooth. An Inlay is placed on the chewing

surface between the cusps of the tooth, while an Onlay covers one or more cusps. Onlays, which
are sometimes called partial crowns, may be used if more than half of the biting surface of the

tooth is decayed or otherwise in need of repair.

References

Berg, J. (2013). Technique for use of stainless- stell cornws in primary molars. Dental Town,

(June), 15.

Bott, R. (2014). A Review of Pulp Therapy for Primary and Immature Permanet Teeth. Igarss

2014, 41(1), 15. http://doi.org/10.1007/s13398-014-0173-7.2

Carotte, P. (n.d.). Endodontic treatment for children. British Dental Journal.

Keith Titley, D. F. and R. (n.d.). Paediatrics: The stainless steel crown- An underused Restroation

in Paediatric Dentistry. Oral Health.

Randall, R. C. (2002). Preformed metal crowns for primary and permanent molar teeth: review

of the literature. Pediatric Dentistry, 24(5), 489500.

Winters, J., Cameron, A. C., & Widmer, R. P. (2013). Pulp therapy for primary and immature

permanent teeth. Handbook of Pediatric Dentistry: Fourth Edition, (6), 103122.

http://doi.org/10.1016/B978-0-7234-3695-9.00007-9