Mechanical Pulp Exposure

Dr. Nudera discusses the steps and protocols for vital pulp therapy, specifically apexogenesis on an 11y/o patient for a mandibular 2nd molar. A long-term follow up is included.

Case Details:

An 11-year-old patient with immature roots experienced a mechanical pulpal exposure during routine caries excavation. The patient was asymptomatic before treatment and remained symptom-free following the exposure. Tooth #31 (mandibular right second molar) demonstrated a visible pulpal exposure on the mesial aspect, confirmed on periapical and bitewing radiographs. Although the periapical image exhibited a minor cone-cut artifact, visualization of the area of interest was adequate and did not warrant retaking the radiograph. Cone beam imaging corroborated the radiographic findings.

While full root canal therapy is often considered in cases of pulpal exposure, this approach presents significant challenges in young teeth with immature, blunderbuss apices and large pulp volumes. These factors complicate debridement, irrigation control, and obturation, increasing the risk of procedural failure. Given the patient’s age, lack of symptoms, and evidence of a healthy vital pulp, vital pulp therapy was determined to be the most appropriate first-line treatment to promote continued root development through apexogenesis.

After a thorough discussion of treatment options with the patient’s parents, direct pulp capping was selected with the understanding that future endodontic intervention would remain an option should pathology develop. Strict aseptic technique was emphasized, as contamination is a primary cause of failure in vital pulp procedures. The tooth was isolated using single-tooth rubber dam isolation with caulking material to ensure an uncontaminated field.

All restorative material and caries were removed to sound dentin, revealing a healthy pulp tissue suitable for direct pulp capping. The exposed area was disinfected using a cotton pellet saturated with 0.5% sodium hypochlorite applied to the preparation and pulp surface without injection. Moisture was removed with a dry cotton pellet. A bioceramic putty material was then placed directly over the pulp exposure at an approximate thickness of 3 mm. The surrounding tooth structure was etched, primed, and bonded, followed by placement of a bonded resin restoration.

Postoperative radiographs demonstrated clear differentiation between the bioceramic material and the bonded restoration. At the one-year follow-up, radiographic evaluation revealed successful apexogenesis with continued root development and apical closure. Additionally, a dentinal bridge was evident beneath the bioceramic pulp cap, indicating reparative dentin formation within the coronal pulp chamber. This biologic response further insulated the pulp and significantly reduced the likelihood of future endodontic intervention.

This case highlights the remarkable healing capacity of vital pulps in young patients and underscores the importance of considering vital pulp therapy as the primary treatment option when managing mechanical exposures in immature permanent teeth.