An 8-year-old male patient was sent for management after 3 days of an enamel-dentine-pulp fracture in the upper left central incisor (number 21) and crown-root fracture with pulp exposure in the upper right central incisor (number 11) (Figures 1-4). Trauma occurred during a football match. The patient denied spontaneous pain on presentation. Through intraoral examination, pulp exposure was diagnosed in both incisors, as well as mild pain to percussion, absence of pain to palpation, absence of periodontal pockets higher than 3 mm, mobility class I, and positive response to cold test in both incisors that were performed on the labial surface. The size of the pulp lesion was registered (nearly 2 mm in tooth 21 and 4 mm in tooth 11) with proliferated pulp reaction in tooth 11. Radiographic examination showed no root fractures or periradicular radiolucency.
The pulpotomy procedure was explained to the parents and the patient who agreed to comply with it. The concerned area was anesthetized with local infiltration of 1.7 ml lidocaine HCL 2% with 1 : 100000 epinephrine. After local anesthesia, the palatine fragment was removed from tooth 11. After this, nearly 2 mm depth of visible pulp tissue and adjacent dentin of both incisors (11 and 21) were removed, with a sterile diamond cylindrical drill on a high-speed handpiece with water irrigation. A hole about 2 mm deep remained, enough to hold the wound dressing and sealing material. Bleeding was controlled with water squirted out of a syringe, and MTA (Pro Root, Dentsply, Tulsa Dental, OK, USA) was applied with a spatula-shaped hand instrument, followed by wet cotton pellets used to adjust it onto the visible pulp space. A layer of MTA 2 mm thick was positioned over the exposed pulp tissue. After 10 minutes, a glass ionomer (Vitrabond Plus, 3M ESPE, USA) was applied over the MTA, and the patient was dismissed (Figure 5). After 2 weeks, the patient was asymptomatic, with no pain to palpation, absence of periodontal pockets higher than 3 mm, mobility class I, and positive response to the cold test. The glass-ionomer restoration was partially removed, and directly bonded composite restoration was performed (IPS Empress Direct, IvoclarVivadent, Schaan, Liechtenstein) with gum retraction (Ultrapak 1, Ultradent, Utah, USA) (Figure 6).
Teeth were followed clinically and radiographically two weeks after treatment and subsequently during the first year at three months, and afterwards, at six-month intervals. During the 6-month follow-up and from 1 to 5 years, the situation remained unchanged with no evidence of radiolucent lesions in radiographic examinations (Figure 7). Cone-beam computerized tomography (CBCT) was used to monitor healing during the 5-year follow-up, allowing 3D visualization of the periapical area and discarding the existence of root resorption (Figure 8).
Follow-up shows a continuation of root development and the creation of hard tissue at the site of the incision (Figure 7). Light discoloration in the crown of 21 was evident at 3 years follow-up (Figure 9), but it did not disturb the patient or his family, so it was not addressed.