“The Resilient Pulp”: Delayed Partial Pulpotomy in the Management of an Enamel-Dentine Fracture with Pulp Exposure

Aim of the presentation:
Partial pulpotomy may prove an appropriate treatment option for delayed presentation enamel-dentine-pulp fractures in closed-apex teeth. In the case presented, a calcium silicate bioceramic was chosen to minimise future tooth discolouration risk, encourage pulpal repair and allow continued formation of dentine (1) in the cervical area.

Summary:
A 16-year-old male was referred by his general dentist for management of a maxillary central incisor with an enamel-dentine fracture with pulp exposure. The coronal tooth fragment was lost through dental trauma. Several immediate calcium hydroxide and glass ionomer dressings had been placed but quickly failed, resulting in repeated pulp exposures. Medically, the patient was healthy. On presentation to secondary care, the exposed pulp was visible, yet responded normally to pulpal testing and periapical tissues appeared normal radiographically. A diagnosis of normal pulp with normal apical tissues, with a finding of complex crown fracture was made. After consideration, the patient opted for partial pulpotomy and direct composite restoration.

Partial pulpotomy was carried out 53 days after initial injury. Under rubber dam, coronal pulp tissue was removed with a sterile high-speed diamond bur and haemostasis achieved using 5.25% sodium hypochlorite irrigation and application of pressure using sterile cotton wool. The tooth was restored with TotalFill BC RRM Fast-Set Putty, Vitrebond and Filtek Supreme direct composite. At 8-week follow-up post-treatment, the tooth remained asymptomatic, responded normally to pulpal testing and had no concerning features clinically or radiographically. Further reviews have been arranged at six months and one year post-injury.

Key learning point:
Pulpotomy may be a suitable treatment for late presentation dental trauma injuries involving pulpal exposure in closed-apex teeth.