Pulpotomy (Vital Amputation)

Pulpotomy (synonym: vital amputation) is an endodontic treatment (treatment of the root canal system including the root apex) that aims to remove the bacterially infected crown pulp (pulp in the crown area of the tooth) while keeping the root pulp vital (alive). The aim of pulpotomy is to keep the tooth painless and free of inflammation in the apical (root) region. It is preferably applied to deciduous teeth, contributing to their placeholder and guide function for permanent teeth.

Indications (areas of application)

  • If the pulp (tooth pulp) of a 1st dentition tooth (deciduous tooth) is opened during excavation (caries removal), it must be assumed that the pulp is contaminated, even if the opening is in the healthy dentin (tooth bone). Since the pulp tissue of the 1st dentition is less reactive than that of the 2nd dentition (permanent teeth) and is therefore unable to seal the opened area with tooth structure, only pulpotomy can be considered as the first measure to preserve the tooth. Only in the case of a very small opening, direct capping can be considered as an alternative.
  • If the carious lesion has already penetrated to the crown pulp, but it can still be assumed that the infection has not yet penetrated to the root pulp (pulp in the roots), so if it is a partial pulpitis of the crown pulp (inflammation limited to the pulp of the tooth crown), the attempt of a pulpotomy is also indicated.
  • After a traumatic (due to a dental accident) pulp opening of the 1st or 2nd dentition, if the pulp was broadly opened and already exposed to the oral environment for some time, thus already shows signs of inflammation.

If the pulpotomy is performed on a tooth of the 1st dentition, this:

  • Not yet be completed in root growth
  • Have a fully formed root
  • Are already in the resorption stage, but still have a root length of at least 2/3.

Contraindications

Tooth preservation by pulpotomy is not indicated if:

  • The pulpotomized tooth cannot be subsequently restored with a filling or deciduous crown due to severe destruction.
  • He is about to physiological exfoliation (the natural tooth loss).
  • He shows radiographic signs of osteolysis in the apex or furcation area (signs of bone dissolution in the area of the root apex or root bifurcation).
  • The root pulp bleeds massively after ablation of the crown pulp, thus is also inflamed.
  • The opened pulp does not bleed, so if it is a pulp necrosis.
  • The pulp secretes serous or purulent (releases aqueous or purulent fluid).
  • The tooth already has a fistula or abscess formation.
  • When there is a lack of compliance (cooperation) of a child patient.

The surgical procedure

The indication for pulpotomy generally arises in the course of filling therapy during caries removal. The procedure is as follows:

  • Local anesthesia (local anesthesia of the tooth), if not already done in advance;
  • If necessary, installation of a rubber dam (tension rubber to shield the tooth from the rest of the oral cavity), if the compliance (cooperation) of the child patient allows this. The rubber dam should prevent saliva access and thus the migration of bacteria, thus creating a treatment field as aseptic as possible;
  • Complete excavation (removal) of the caries;
  • Removal of the chamber roof of the crown pulp, e.g., with the help of a spherical diamond cutter;
  • Amputation (removal) of the crown pulp with the grinder up to the root canal entrances, preferably under irrigation with saline solution (NaCl); alternatively, electrosurgical ablation is possible.
  • Successful hemostasis is a crucial treatment step; as the formation of a blood clot must be prevented. As an ideal hemostyptic (drug to stop bleeding) 15.5% ferric sulfate solution, applied for 15 sec, has proven to be effective.
  • Wound dressing , for example, with calcium hydroxide, fast curing zinc oxide eugenol cement (ZOE cement) or mineral trioxide aggregate (MTA); the highest clinical success rate shows here MTA, followed by ZOE cement.
  • Covering with Flow (flowable resin filling material), preferably using the dentin adhesive technique;
  • Final filling or better: build-up filling and insertion of a prefabricated milk tooth steel crown.

Possible complications

Complications arise primarily:

  • Due to bacterial infestation of the remaining root pulp at the time of amputation.
  • From a failure of hemostasis due to associated coagulation.
  • From the lack of sealing against the bacterial oral environment by the final care.

As a result, may develop:

  • A residual pulpitis (inflammation of the remaining pulp).
  • An apical periodontitis (inflammation of the periodontium (periodontium) just below the tooth root; apical = “tooth rootward”), associated with osteolysis (bone dissolution) and possibly with damage to the underlying tooth germ of the 2nd dentition.
  • Internal resorptions (dissolution of the tooth from the inside).
  • Fistula or abscess formation.