Management of Deep Carious Lesions in

Children
The principal goal of pediatric operative dentistry is to prevent the extension of
dental disease and to restore damaged teeth to healthy function. Pulp exposure is
caused most commonly by caries but may also occur during cavity preparation or by
fracture of the crown. Pulp exposures caused by caries occur more frequently in
primary than in permanent teeth because primary teeth have relatively large pulp
chambers, more prominent pulp horns and thinner enamel and dentine. In primary
molars with proximal cavities pulp involvement occurs in about 85 % of those with
broken marginal ridges.
Differences between primary and permanent teeth that modify pulp therapy
techniques:
- Pulp chamber anatomy in primary teeth approximates the surface shape of
the crown more closely than in permanent teeth.
- Pulp chamber of primary teeth is proportionately larger with higher pulp
horns.
- The pulp protecting dentin thickness between the pulp chamber and the
dentino-enamel junction is less than in permanent teeth.
- Canals of primary molars have many lateral branches and apical
ramifications → Complete extirpation of pulp issues is difficult.
- Accessory canals at furcation area→ Radiolucency seen at inter-radicular
region rather than the periapical region (Radiographically).
- The roots of primary molars flare outward from the cervical part of the
tooth to a greater degree than permanent teeth and continue to flare apically
to accommodate the underlying succedaneuos tooth follicle.
- Less number of nerve fibers → reduced sensitivity to pain.
 - The roots of primary teeth undergo physiologic root resorption; thus, the
requirements of primary root canal filling materials must encompass
germicidal action, good obturation and resorbable capability.
Clinical Classification of Pulp Pathology:
Based on the extent of pulp damage, disease of the pulp can be classified into:
1. Pulpitis:
- Reversible pulpitis: It is a mild to moderate inflammation of the pulp
caused by noxious stimuli, in which it is capable of returning to the un-
inflamed state following removal of the stimuli.
Symptoms: Sharp pain lasting for a moment subsides after removal of the
stimuli.
- Irreversible pulpitis: Pulp is incapable of returning to the un-inflamed state
following removal of the stimuli.
Symptoms: spontaneous pain persisting after removal of stimulus and may
be referred to adjacent teeth.
Chronic hyperplastic pulpitis: Also called pulp polyp, occurs in teeth with
extensive carious pulp exposures due to long-standing low-grade irritation,
characterized by presence of a granulation tissue covered by epithelium,
usually asymptomatic.
2. Pulp necrosis: It is due to death of the pulp, may be partial or total. The tooth
may be asymptomatic, and discoloration of the crown occurs.
The success of the treatment used depends mainly upon an accurate diagnosis. Pre-
requisite for correct diagnosis:
- Complete case history.
- Proper examination.
- Investigations.
Diagnostic aids in selection of teeth for vital pulp therapy:
I. History:
1. Pain History:
An accurate history of the type of pain must be obtained, including its duration,
frequency, location and spread as well as aggravating and relieving factors.
In primary dentition, the pain history rarely provides very clear information, but a
history of spontaneous pain does appear to correlate well with advanced, irreversible
pulpitis.
The dentist should distinguish between two types of pain:
• Provoked pain: is precipitated by stimulus (thermal, chemical or mechanical)
and disappears after removal of stimulus. For example:
- Pain associated with eating is due to pressure from accumulated food
within the carious lesion and chemical irritation to the vital pulp protected
by a thin layer of dentine (good prognosis).
- Pain due to cold or hot food or drinks may indicate hyperemia or reversible
pulpitis.
• Spontaneous pain (Unprovoked pain): is a throbbing constant pain that may
keep the patient awake at night. It indicates advanced pulp damage irreversible
pulpitis (poor prognosis).
• Swelling and tenderness on biting: may indicate loss of pulp vitality and
periapical periodontitis.
While positive history of toothache suggests definite pulp pathology, absence of
pain does not preclude pulp involvement.
2. Medical History:
The child’s general medical history should also be reviewed to exclude any systemic
disorders or medications of dental relevance.
Examples may include:
- Children with bleeding disorder.
 - Children with rheumatic fever.
- Immune-compromised children.
In case of medically compromised children extraction of the involved tooth is the
treatment of choice after proper premedication, as pulp may not possess a normal
reparative power.
3. Previous dental history:
A brief review of the child’s previous history may reveal important information on
the family’s general attitude to dentistry.
II. Clinical Examination:
1. Extra-oral examination:
Facial cellulitis or the presence of enlarged lymph nodes.
Extra-oral swelling: it is due to the spread of exudate into various spaces along the
facial planes. The drainage occurs through the path of least resistance, which is
through the skin.
2. Intra-oral examination:
a. Inspection: inspection of all teeth and associated soft tissues before focusing on
suspected problem area. Note should be made of any carious lesions, fractured or
displaced restorations, discolored teeth and areas of soft tissue swellings.
b. Intraoral swelling: it is usually apparent at the buccal surface of the alveolus
because there is less bone on this aspect than on the lingual or palatal side, through
which inflammatory products from the inter radicular or the periapical regions
penetrate taking the path of least resistance. The presence of swelling, sinus, draining
fistula or chronic abscess indicates a non-vital pulp.
c. Palpation: to check for any deviation in bony contour, which may be present
denoting periapical lesion.
d. Mobility: associated with deciduous teeth may physiologic or may be due to any
persisting pathology.
e. Sensitivity to percussion: indicates apical or periodontal inflammation or both.
f. Discoloration: non-vital teeth tend to have a darker color. Tooth associated with
internal resorption at the pulp chamber tend to appear pink (Hence the name Pink
Tooth).
g. Size of pulp exposure and amount of pulpal bleeding: are the most valuable
observations in diagnosing the condition of the primary pulp:
- Small pin-point exposure surrounded by sound dentine indicates favorable
condition for vital pulp therapy.
- Large exposure with watery exudate or pus indicates unfavorable condition
for vital pulp therapy.
- Small controllable amount of bleeding during and/or following pulp
amputation is a favorable condition for vital pulp therapy (pulpotomy).
- Excessive uncontrollable bleeding during and/or following pulp amputation
is an unfavorable condition for vital pulp therapy.

III. Vitality tests:

Sensitivity test will rarely give a clear picture of the extent of pulpal inflammation
and the results should be interpreted with caution. Anxious children may give an
exaggerated response to relatively minor stimulation of a healthy tooth. While poorly
innervated, immature teeth, or teeth which have been concussed by trauma may give
no response in the presence of advanced inflammation.

There are many methods to assess the pulp sensitivity among them: Thermal pulp
test (hot or cold), Electric pulp tester and Laser doppler flowmeter.
Thermal test:
- Application of hot (gutta percha or hot instrument) or cold (ice cone).
- The reaction of normal tooth is tested first.
 - Normal response: pain disappear after removal of stimulus.
- If pain persists, indicate pulpitis or hyperemia.
- If no pain is an indication of non-vital pulp.
- Ice is best for children.
Electric pulp tester:
- Record the reading of a normal tooth first.
- If the affected tooth responds at a lower reading than normal, this indicates
hyperemia or pulpitis.
- If the affected tooth responds at a higher reading, this indicates pulp
degeneration.
- 40% of irreversible pulps respond like controls.
- 70% of non-vital teeth give no response.
- 20% of vital teeth give no response.
Disadvantages of electric pulp tester:
a- Child may become apprehensive and gives a false positive response.
b- Pulp tester may give false positive response when content of pulp is liquid
(liquefaction necrosis).

IV. Radiographic examination:

Periapical and bitewings radiographs are used to examine periapical area and
supporting bone. Pulp exposure cannot be accurately detected from an X-ray film.
Radiographic examination in children is more difficult than adult?
- Young permanent teeth may have incompletely formed root ends giving an
impression of periapical radiolucency.
- The roots of primary teeth undergoing normal physiologic resorption may
present a misleading picture of pathologic changes.
- Permanent teeth may be superimposed on the primary teeth.
Radiographs are valuable for determining the following:
- Proximity of caries or previous restoration to pulp.
- Internal (in case of vital pulp due to osteoclastic activity) or external (in case
with a non-vital pulp) root resorption.
- Calcified masses within pulp chamber and root canals.
- Periapical changes such as widening of periodontal membrane space.
- The presence of apical or furcation pathosis.
- Bone resorption.

➢ Teeth exhibiting provoked pain of short duration relieved with over-the-

counter analgesics, by brushing, or upon the removal of the stimulus and
without signs or symptoms of irreversible pulpitis, have a clinical diagnosis
of reversible pulpitis and are candidates for vital pulp therapy.
➢ Teeth exhibiting a history of spontaneous unprovoked pain, a sinus tract,
swelling, mobility not associated with trauma or exfoliation, furcation/apical
radiolucency, or radiographic evidence of internal/external resorption have a
clinical diagnosis of irreversible pulpitis or necrosis. These teeth are
candidates for non-vital pulp treatment. (Put into consideration the tooth
restorability and life expectancy of the tooth).

Pulp Therapy Techniques

A. Vital pulp therapy techniques:
I. Pulp capping:
The aim of pulp capping is to maintain pulp vitality by placing a suitable dressing
either directly on the exposed pulp (direct pulp capping) or on a thin residual layer
of slightly soft dentine (indirect pulp capping).
1. Indirect pulp capping:
Definition: It is the technique used to avoid potential pulp exposure, by capping the
thin layer of dentine overlying a macroscopically unexposed pulp with a layer of
lining or cement material with the intention of preserving pulp vitality.
Indications:
- Favorable diagnostic criteria.
- Primary and young permanent teeth.
- Deep carious lesions with close proximity to the pulp.
- Asymptomatic tooth without clinical or radiographic evidence of pulp disease.
Technique:
First visit:
- Local anesthesia and isolation.
- Access to the cavity and prepare the cavity to standard outline.
- Gross caries is excavated from the carious lesion, leave last layer of carious
dentin (affected).
- A radiopaque liner such as a dentine bonding agent, resin modified glass
ionomer, calcium hydroxide, zinc oxide eugenol, or glass ionomer cement is
placed over the remaining carious dentine to stimulate healing and repair, (6-8
weeks).
Second visit (Re-evaluation visit):
- The tooth is re-entered, and any remaining carious dentin is carefully removed.
Apply calcium hydroxide dressing and restore the tooth in usual manner.
- Current literature indicates that there is no conclusive evidence that it is
necessary to re-enter the tooth to remove the residual caries. As long as the
tooth remains sealed from bacterial contamination, the prognosis is good for
caries to arrest and reparative dentin to be formed to protect the pulp.
By the end of pulp capping, treatment is judged successful if there is:
- No sensitivity to percussion.
 - No history of pain following treatment.
- No radiographic evidence of periapical pathosis or root resorption.
- No clinical evidence of pulp exposure if the tooth was re-entered.
2. Direct pulp capping:
Definition: is the procedure of covering the exposed vital pulp with a material that
promotes healing.
Aim: promote healing and repair of the vital pulp tissues.
Exposure: mechanical or traumatic pin-point exposure surrounded by sound
dentine.
Indications:
- Small pinpoint exposure surrounded by sound dentin, produced accidentally
during cavity preparation or due to trauma (recent trauma within 6 hours).
- Normal vital pulp.
- Absence of pain.
- No bleeding at exposure site or an amount that considered normal.
- Normal radiographic findings.
- Teeth with open apices (young permanent teeth).
Technique:
- Local anesthesia and isolation.
- Gentle irrigation with saline or distilled water.
- The hemorrhage arrested with light pressure from moisten cotton pellets.
- Apply the capping material (calcium hydroxide).
- Restore the tooth.
Direct pulp capping is generally contra-indicated for primary teeth due to:
As the success of pulp capping depends upon the presence of young tissues which
can regenerate, in primary teeth tissues ages early (contain less cellular elements).
Also, there is rapid spread of inflammation throughout the primary coronal pulp, due
to increased blood supply. Therefore, there is less chance that the infection will be
limited to the exposed part of the pulp.

Therefore:
Minute Pulp exposures in permanent teeth →Vital pulp capping is the treatment of
choice.
Minute Pulp exposures in deciduous teeth →Vital Pulpotomy is the treatment of
choice.
II. Pulpotomy:
Definition: is the complete amputation of the coronal pulp tissues of vital pulp till
the entrance of the radicular pulp.
A pulpotomy is performed in a primary tooth with extensive caries but without
evidence of radicular pathology when caries removal results in a carious or
mechanical pulp exposure.
Objectives: To remove the inflamed and infected pulp tissue and allowing the vital
pulp in the root canals to heal, thus maintaining the vitality of the tooth.
Indications:
- Carious or traumatic exposure in vital primary teeth.
- Slight amount of bleeding at exposure site which is considered within
normal.
- No history of spontaneous or persistent pain.
- Normal clinical and radiographic signs (Absence of abscess or sinus, no
internal resorption or inter-radicular bone loss).
Contra-indications:
- Cardiac conditions.
- Spontaneous pain or pain at night.
 - Swelling.
- Tenderness to percussion.
- Pathologic internal or external root resorption.
It can be classified according to the treatment objectives into:
- Devitalization: This procedure is based on complete fixation of underlying
radicular pulp tissue thereby avoiding infection and internal resorption
(Formocresol pulpotomy).
• Formaldehyde in formocresol is a strong tissue fixative and has an
antimicrobial action. Tissue fixation is achieved by chemical binding
of formaldehyde with proteins in pulp cells, while its bactericidal
effect is achieved by chemical binding to proteins of microorganisms.
• Histologically, formocresol produces progressive fixation of pulp
tissue with ultimate fibrosis of the entire pulp.
- Preservation: This procedure produces only minimal insult to underlying
pulp tissue without initiating an inductive process, thereby preserving
maximum radicular pulp tissue. This is achieved by using Glutaraldehyde or
Ferric sulphate.
• Glutaraldehyde: Similar to formaldehyde, glutaraldehyde fixes
proteins of the pulp cells. However, molecules of glutaraldehyde
are larger than formaldehyde which limits its penetration into the
underlying pulp tissue. Moreover, binding of glutaraldehyde to
proteins of pulp cells is stronger and irreversible.
- Histologically, when glutaraldehyde is placed over vital pulp tissue it
produces an initial zone of fixation which does not migrate apically. The
tissue underlying this fixed zone had cellular details of normal pulp which
suggests that the vitality of the remaining pulp is maintained. The material
 is used as 2% or 5% buffered glutaraldehyde solution for pulpotomy
technique in primary teeth.
• Ferric sulphate: it is non-aldehyde chemical which is used as
15.5% solution for pulpotomy technique in primary teeth based on
its hemostatic and coagulative properties.
- Histologically, when ferric sulphate is applied to amputated pulp tissue,
blood reacts with ferric and sulphate ions which cause agglutination of blood
proteins. These agglutination of blood proteins. These agglutinated proteins
from plugs to occlude the capillary orifices which produce chemical sealing
of the cut blood vessels.

- Regeneration pulpotomy: this procedure is based on induction of reparative

dentin formation by the pulp capping agent, thereby leaving the underlying
radicular pulp tissue vital and healthy. This could be achieved by using
Calcium hydroxide, Mineral trioxide aggregate, Freeze dried bone and Bone
Morphogenic protein.

• Calcium hydroxide: it is highly alkaline material with pH 12. It

consists mainly of calcium and hydroxyl ions. The calcium ions
stimulate cellular proliferation in pulp tissue. The hydroxyl ions
maintain a state of alkalinity important for cell proliferation and
produce an antiseptic effect. It is used in pulpotomy technique in
young permanent teeth.
• Histologically, the pulp tissue underneath the calcium hydroxide
remains vital and organizes an odontoblastic layer to lay down
 reparative dentin which gives a chance for the root to complete its
apical growth.
• One month after the capping procedure, a calcified bridge is
evident radiographically. This bridge increases in thickness during
the next 12 months. The pulp beneath the calcified bridge remains
vital and free from inflammatory cells.
• Mineral trioxide aggregate: a pulp capping agent with excellent
sealing ability. It is highly biocompatible with potent antimicrobial
properties due to its high alkalinity (pH 12.5). The material has the
ability to stimulate dentin bridge formation adjacent to dental pulp.

- Non-Pharmacotherapeutic approaches: Electrocautery pulpotomy and

Laser pulpotomy.
a- Electrocautery pulpotomy: it is known as non-chemical devitalization.
Its mechanism of action is cauterization of pulp tissue.
b- Laser pulpotomy: it produces superficial zone of coagulation necrosis
which remains compatible with underlying tissues and isolates the pulp
from vigorous effects of external stimuli.

According to the capping material, vital pulpotomy can be classified into

Formocresol (indicated in primary teeth) and calcium hydroxide pulpotomy
(indicated in young permanent teeth).

Formocresol pulpotomy:
Constituents of Buckley’s formocresol:
- Tricresol 35%.
- Formaldehyde 19%.
- Glycerol 15%.
- Water 31%.
It is now recommended to use 1/5 dilution:
- Buckley’s formocresol: 1 part.
- Glycerol: 3 parts.
- Water: 1 part.
Technique:
- Local anesthesia and isolation.
- Establish outline form to ensure access to the pulp chamber.
- Remove all carious dentine with round bur and spoon excavator, this ensures
a clean operating field.

- Remove the roof of pulp chamber using bur No. 330.

- Remove any overhanging ledges of dentin as pulp tissue under ledges may
not be easy to remove.
- Amputate the coronal pulp tissue with a large spoon excavator or with a
large round bur at low speed carefully to avoid perforation of the floor of the
pulp chamber.
- Wash and flush the pulp chamber with sterile water or saline solution.
- Dry and control bleeding with sterile cotton pellets for about 4 minutes.

- After amputation of the coronal pulp, control of bleeding and formation of

a blood clot, apply a cotton pellet moistened with formocresol and blotted
on a sterile cotton roll to remove the excess over the radicular pulp stumps
for 4-5 minutes. On removal pulp stumps appear dark brown with minimal
oozing of blood.
- Prepare a paste of zinc oxide-eugenol. Remove the cotton pellet moistened
with formocresol and place enough paste to cover the radicular pulp stumps.
- Pressure should be avoided on radicular pulp tissues.
- A base is placed (as Zinc phosphate or glass ionomer) and prepare the tooth
for a stainless-steel crown.

- A stainless-steel crown is the ideal restoration after pulpotomy because the

crown of the tooth is brittle and may fracture.
B. Non-vital pulp therapy techniques:
I-Pulpectomy
Definition:
Pulpectomy is a root canal procedure for pulp tissue that is irreversibly infected or
necrotic due to caries or trauma. Pulpectomy involves removal of roof and contents
of pulp chamber in order to gain access to the root canals which are debrided, cleaned
and disinfected; the canals are filled with resorbable material.

Indications of pulpectomy:
- Primary tooth with irreversible pulpitis or necrosis.
- A tooth treatment planned for pulpotomy in which the radicular pulp exhibits
clinical signs of irreversible pulpitis (e.g., excessive haemorrhage that is not
controlled with a damp cotton pellet applied for several minutes) or pulp necrosis
(e.g., suppuration, purulence).
- No evidence of pathologic conditions with root resorption not more than 2/3rd of
roots length.
Objectives:
- To remove irreversibly inflamed or necrotic radicular pulp tissue and gently
clean the root canal system.
- To obturate the root canals with a filling material that will resorb at the same
rate as the primary tooth and be eliminated rapidly if accidentally extruded
through the apex
- Following treatment,
- The radiographic radiolucent areas should resolve in 6 months as evidenced
by bone deposition
- Pre-treatment clinical signs and symptoms should resolve within 2 weeks.
- The treatment should permit resorption of primary tooth root and filling
materials at the appropriate time to permit normal eruption of the
succedaneous tooth.
Technique:
Single visit or multi-visit pulpectomy may be undertaken depending on whether the
radicular pulp is irreversibly inflamed or non-vital (with/without an associated
periradicular pathosis). If infection is present, and the presence of an exudates does
not allow drying of the canal, consideration should be given to the two-stage
pulpectomy technique.

- Pre-operative radiograph showing all roots and their apices.

- Local anaesthetic (to enable use of rubber dam clamp).
- Rubber dam mandatory.
- Removal of caries.
- Removal of roof of pulp chamber preferably with non-end cutting bur.
 - Removal of any remains of coronal pulp tissue with sharp sterile excavator or
large bur in slow handpiece.
➢ Note whether radicular pulp is bleeding (one-stage procedure) or necrotic
(usually requiring two-stage procedure).
- Identify root canals.
- Irrigate with normal saline, Chlorhexidine solution (0.4%) or and sodium
hypochlorite solution (0.1%).
(Disinfection with irrigants such as one percent sodium hypochlorite and/or
chlorhexidine is an important step in assuring optimal bacterial
decontamination of the canals. But sodium hypochlorite must not be extruded
beyond the Apex because it is a potent tissue tissue irritant).
- Estimate working lengths of root canals keeping 2 mm short of the
radiographic apex.
- Insert small files (no greater than size 30) into canals and file canal walls
lightly and gently.
- Irrigate the root canals then dry them with pre-measured paper points, keeping
2 mm from root apices.
- If infection present (canal exudate and/or associated sinus) dress root canals
with non-setting calcium hydroxide and temporize (two-stage procedure.
- If canals can be dried with paper points, obdurate root canals by injecting or
packing a resorbable paste. (e.g., slow-setting pure zinc oxide eugenol, non-
setting calcium hydroxide paste or calcium hydroxide and iodoform paste
(Vitapex TM or Endoflas)
Definitive restoration to achieve optimum external coronal seal (ideally a preformed
crown).

Problems encountered in deciduous teeth pulpectomy:

The multiple ramifications of the radicular pulp in a primary molar make complete
debridement impossible. Also, the ribbon shape of the root canals, with a narrow
mesiodistal width compared to their buccolingual dimension, discourages gross
enlargement of the canals that may result in lateral perforation of the canals.

Note:
- Due to these problems encountered in primary molars an alternative
technique called partial pulpectomy can be used. This technique includes
removal of coronal pulp tissue and as much as possible from the content of
the root canal without interfering deeply into the apical portion.
- Primary molar pulpectomy is achievable with practice and appropriate
patient selection especially after the advances in chemo-mechanical
preparation (i.e.: irrigants, instruments, obturating material).
II. Non-vital or Mortal pulpotomy (no longer used):
Ideally a non-vital tooth should be treated by pulpectomy.
Technique of mortal pulpotomy:
- Necrotic coronal pulp tissue is removed as pulpotomy.
- A cotton pellet moistened with formocresol is placed over the radicular pulp
stumps and covered with intermediate filling material.
- At the second visit after 7-10 days, isolate tooth with rubber dam without
local anesthesia, remove the dressing and pellet.
- Press the paste in the root canals with a cotton pellet and restore the tooth in
normal manner.
III. Lesion sterilization and tissue repair (LSTR):
- It involves the placement of antibiotic mixture in the pulp chamber of the
tooth to disinfect the root canals.
 - Antibiotic mixtures that could be used include: triple antibiotic paste
(metronidazole, ciprofloxacin and minocycline (TAP)), modified triple
antibiotic paste (metronidazole, ciprofloxacin and clindamycin (MTAP)) or
double antibiotic paste (ciprofloxacin and metronidazole (DAP))
- The canal should be filed/ broached to ensure the placement of the paste in
the pulp chamber or a medication cavity can be formed (the canals orifices
are enlarged using a round burs to form the medication cavity which is 1mm
in diameter and 2 mm in depth).
- LSTR should be chosen over pulpectomy in teeth with root resorption or to
retain teeth for up to 12 months that otherwise would be extracted.
- It is indicated for primary teeth with significant root resorption (external
greater than one millimeter (mm) and/ or internal) needing non-vital pulp
therapy.
- It is also indicated when the clinician decides not to extract the tooth with
significant preoperative root resorption, LSTR should be the choice over
pulpectomy to save such teeth for up to 12 months but if retained longer
should be monitored with periodic clinical exams and radiographs at least
every 12 months after doing LSTR.

Failures following pulp therapy:

1. Internal root resorption:
- Occurs within pulp canals several months following pulpotomy.
- It is destructive process due to osteoclastic activity.
- Pulp canals become widened, walls become thin and perforation may occur.
Etiology:
- A true carious pulp exposure is usually associated with some degree of
inflammation. This inflammation may be limited to coronal pulp tissue or may
 extend to the entrance of pulp canals. Osteoclasts may become attracted to the
area and initiate resorption.
- All capping materials are irritating and produce some degree of inflammation,
inflammatory cells in the area of inflammation may attract osteoclasts which
initiate internal resorption.
- Because the roots of primary teeth are undergoing normal physiological
resorption there is osteoclastic activity in the area which may predispose the
tooth to internal resorption.
2. Alveolar abscess:
- Develops several months following pulp therapy.
- Infection may be present in bone around root apex or more commonly in
bifurcation area.
- May be associated with fistula in chronic conditions.
- Primary teeth which develop an alveolar abscess should be removed, while
permanent teeth can be treated endodontically.

Pulp therapy for young permanent teeth:

I. Apexogenesis (Calcium hydroxide pulpotomy):
Indications:
- Vital exposures in young permanent teeth with immature root.
- Exposed young permanent teeth due to trauma.
Aim:
- To maintain the radicular pulp vital to allow complete root development.
- Calcium hydroxide placed over radicular pulp stumps stimulates the
formation of a calcific bridge and successful root closure.
II. Apexification (root end closure in non-vital teeth):
A technique used to induce the formation of mineralized dental tissues at the apical
pulp region of non-vital permanent tooth with incompletely formed root.
Indications:
- Permanent tooth with non-vital pulp and incompletely formed apices.
Aim:
- To promote root elongation and or calcific root closure. Even though the
pulp is necrotic, epithelial root sheath of Hertwig persists and allows
regeneration.
A. Calcium hydroxide apexification:
Historically, long-term calcium hydroxide treatment was used to induce
apexification of the immature tooth with pulpal necrosis.

Technique:
- The entire pulp is removed, and calcium hydroxide is used to fill the root
canals and is replaced every 3-4 months until apical closure occurs. The
tooth is then treated with root canal therapy.
Disadvantages of calcium hydroxide apexification:
- The time required for formation of the calcified barrier (3-24 months).
- Multiple appointments needed for reapplication of calcium hydroxide.
- The effect of long-term (several months or more) calcium hydroxide on the
mechanical properties of dentin (exposure to calcium hydroxide denatures
the carboxylate and phosphate groups in dentin).
 UK guidelines 2010 stated that: "In-vivo and ex-vivo studies have demonstrated
that prolonged dressing of non-vital immature teeth with non-setting calcium
hydroxide results in a reduction in the fracture strength of root dentine.

Working length determination placement of Ca(OH)2 after 3 months

Ca(OH)2 placed again 10 month Tooth was obturated

B. Apical barrier technique (MTA apical plug):

It is defined as the non-surgical condensation of a biocompatible material into the
apical end of the root canal in order to establish an apical stop that allow root canal
to be immediately filled.
- The use of Mineral Trioxide Aggregate (MTA) has become an accepted
method of creating an apical barrier in non-vital immature teeth and promotes
periapical healing.
Technique:
 - Removing the coronal and nonvital radicular tissue just short of the root end
and placing a biocompatible agent such as calcium hydroxide in the canals for
two to four weeks to disinfect the canal space.
- The production of an apical barrier using MTA can usually be achieved in a
single visit. Subsequently, the remainder of the root canal may be obturated.
- The coronal part of the canal should be restored using composite resin to
reinforce the neck of the tooth and reduce the risk of fracture.
- MTA has several favorable characteristics including biocompatibility,
antimicrobial activity, prevention of bacterial leakage, no cytotoxicity, and
can stimulate cytokine release from bone cells to promote hard tissue
formation. It also has a shorter treatment time compared with calcium
hydroxide, and a more predictable time to apical
closure.

III. Regenerative endodontic therapy:

It is a biologically based procedure designed to replace damaged, diseased, or
missing structures, including dentin, root structures as well as cells of the pulp-dentin
complex with live viable tissues, preferably of the same origin, that restore the
normal physiologic functions of the pulp-dentin complex.
There are three components play essential roles in the restoration of previously
damaged structures:
1. Stem/progenitor cells
2. Morphogenetic signals
 3. Three-dimensional (3D) scaffolds.
Indications:
- Tooth with necrotic pulp and an immature apex.
- Pulp space not needed for post/core final restoration.
- Compliant patient/parent.
- Patients not allergic to medicaments and antibiotics necessary to complete
procedure.
Procedures:
First Appointment
- Local anesthesia, dental dam isolation and access.
- Copious, gentle irrigation with 20 mL NaOCl using an irrigation system that
minimizes the possibility of extrusion of irrigants into the periapical space.
Lower concentrations of NaOCl are advised (1.5%, 20 mL/canal, 5 min),
irrigated with saline (20 mL/canal, 5 min), irrigating needle positioned about
1 mm from root end.
- Dry canals with paper points.

Second Appointment (1 - 4 weeks after 1st visit)

- Assess response to initial treatment.
- Anesthesia with 3% mepivacaine without vasoconstrictor, dental dam
isolation.
 - Copious gentle irrigation with 20 mL of 17% EDTA.
- Dry with paper points.
- Create bleeding into canal system by over-instrumenting.
- Stop bleeding at a level that allows for 3 - 4 mm of restorative material.
- Place a resorbable matrix over the blood clot of necessary and white MTA as
coronal seal.

Follow-up (6-, 12-, 24-months):

Clinical and Radiographic examination:
- No pain, soft tissue swelling or sinus tract (often observed between first and
second appointments).
- Resolution of apical radiolucency (often observed 6-12 months after
treatment).
- Increased width of root walls (this is generally observed before apparent
increase in root length and often occurs 12-24 months after treatment).
- Increased root length.
- Positive pulp vitality test response.
- Recommended yearly follow-up after the first 2 years.
 The characteristics of three treatment procedures for immature root formation:
Procedure Characteristic

- Long time span of the entire treatment.

Apexification with calcium - Multiple visits.

hydroxide: - Increased risk of tooth fracture due to long-term application of Ca(OH)2.

- One- or two-step apexification.

- Neither strengthens the root nor promotes further root development.
Apexification with MTA:
- Roots remain thin and fragile.
- Promotes further root development.
- Causes reinforcement of dentinal walls by deposition of hard tissue
Revascularization:
(strengthening the root against fracture).