Case Report: Immediate pain relief after partial pulpotomy of cariously exposed young permanent molar using mineral trioxide aggregate and root maturation, with two years follow-up

Introduction

Symptomatic young permanent first molar is a widespread event, since this is the first permanent tooth erupting in the oral cavity and parents may consider it replaceable as the rest of the child's baby teeth. The primary goal for treating those teeth is to maintain healthy pulp to allow the root to continue maturation both in length and width.

Partial pulpotomy is considered as promising modality for treatment of immature permanent teeth with carious pulp exposure. This technique consists of excavation of 2–3 mm inflamed coronal pulp tissue, and the remaining pulp is then capped with dressing material that maintains its viability and promotes healing. When comparing partial with cervical pulpotomy, partial pulpotomy preserves the cell-rich coronal pulp tissue, which is necessary for healing and the formation of dentin bridge in the coronal area. Cervical pulpotomy, on the contrary, removes all the coronal pulp, with an increased risk of cervical fracture due to the loss of physiologic dentin apposition¹.

In a previous study, partial pulpotomy gave a high clinical success rate (91–93%) in asymptomatic young permanent molars with deep caries^1–3. However, some case reports reveal that partial pulpotomy may have good prognosis also in symptomatic teeth⁴. In addition, a randomised clinical trial reported treating molars with irreversible pulpitis using partial pulpotomy, and the results were promising⁵.

Choice of capping materials or medicaments can have a massive influence on vital pulp therapy success. Mineral trioxide aggregate (MTA) is considered the gold standard of pulp dressing material. MTA provides a long-term seal, acceptable biocompatibility, and dentinal bridge formation⁶. Roberts et al. review in 2008 showed that MTA has excellent potential as a pulpotomy medicament, and can form hydroxyapatite when exposed to physiologic solutions⁷.

This case report presents the treatment of pulpitis in young permanent molar using MTA-Angelos partial pulpotomy.

Case report

Diagnostic assessment

Clinical and radiographic examinations showed caries in the lower right first permanent molar approaching the pulp. The molar showed incomplete root formation (Figure 1). The diagnosis was acute pulpitis at lower right first permanent molar. Partial pulpotomy was proposed to allow root formation.

Figure 1. Preoperative radiograph showing deep, curious permanent first molar with blunder-bus open apex and no signs of a periapical lesion.

Procedure

We began with the administration of inferior alveolar nerve block (Table 1, item 1), followed by isolation of the tooth using a rubber dam (Table 1, item 2). Removal of caries using a suitable round carbide bur under a copious amount of water coolant was done, then spoon excavator was used to excavate pulp through the exposed part. To control bleeding, gentle flush to the wound with distilled water until bleeding was controlled was performed and a lightly packed cotton pellet was applied. MTA-Angelus (Table 1, item 3) was freshly mixed following manufacturer’s directions immediately before being placed and condensed gently over wet cotton against the fresh pulp wound. Excess material was scraped off the application of moistened cotton for 15 minutes to allow initial setting⁸. Subsequently, a self-cure glass ionomer (Table 1, item 4) was applied as a base material at 2 mm thickness. Final restoration using composite was performed (Table 1, item 5)^6,9. A periapical radiograph was taken as a baseline record for comparison with follow-up appointments (Figure 2).

Table 1. Materials used in the process of partial pulpotomy used in a case of acute pulpitis.

1	Septodont, Scandonest® 2% L Mepivacaine HCl. 2% and Levonordefrin 1:20,000 Injection, USP
2	Roeko Flexi-Dam - Purple Non-Latex Coltène/Whaledent Ltd., UK
3	Industria de Produtos Odontofogicos Ltda, Londrina, Brazil
4	Riva Self Cure Capsules regular set, A2, and A3, SDI, Cologne Germany
5	Zhermack SpA - Via Bovazecchino, 100 45021 Badia Polesine (RO), Italy

Figure 2. Radiograph immediately after partial pulpotomy procedure is taken as a baseline record.

Follow-up and outcomes

On the following day, a postoperative phone call to the patient’s parents revealed that the patient felt pain relief.

At one week follow-up, the tooth responded to thermal pulpal tests within reasonable limits. After three months, pulpal sensitivity test gave a normal reading, and clinical and radiographic examinations were normal. The patient continues to be followed up every three months with no complaints from the treated tooth for 12 months, and the root showed complete maturation (Figure 3). After that, the patient was lost to follow-up. Twenty-four months later the patient came back to the clinic for treatment of a different tooth, and a lower right first permanent molar examination showed clinical and radiographic success (Figure 4).

Figure 3. Twelve months follow up radiograph showing root maturation.

Figure 4. Twenty-four months follow up radiograph showing normal periapical area and root.

Discussion

Partial pulpotomy technique obtains good clinical outcomes with different capping materials^4,5. MTA is considered the gold standard for vital pulp therapy⁶. MTA has excellent sealing ability and biological properties that preserve the pulp viability in immature permanent teeth with irreversible pulpitis^10,11. Partial pulpotomy using MTA, as opposed to root canal therapy or apexification, is more conservative and allows root maturation both in length and width⁴, and this was observed in our case report.

Conclusions

MTA-Angelus partial pulpotomy appears to be a successful treatment for symptomatic immature permanent teeth with deep caries and vital pulps. However, we recommend conducting more clinical studies with a large sample size and longer follow-up period to validate our observations. Partial pulpotomy technique should also be tested in older ages with mature roots.

Consent

After the full explanation of the procedure, written informed consent was taken from the parent of the child.

The patient's mother gave written informed consent for the publication of this case report and any associated images.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.