the clinical and radiographic findings of traumatic dental injury reveal a loss of tooth structure with pulp exposure , which is commonly referred to in dental literature as complicated crown fracture .
the majority of these injuries occur in recently erupted or young permanent teeth that have immature roots .
the treatment planning is influenced by the extent of the exposure of the pulp to the oral environment , the degree of root development and the time interval between the traumatic dental injury and the examination .
the treatment strategy of the crown fracture after pulp exposure is dictated by the concern for vitality of the dental pulp for continued root development of immature permanent teeth .
pulp preservation by vital pulp therapy includes pulp capping and pulpotomy in complicated crown fractures of immature permanent incisors .
pulp capping is recommended for small exposure that occurred not more than a few hours previously . as the exposure site was large or the elapsed time was long between the accident and examination , partial pulpotomy was considered as the treatment of choice .
conversely , in mature teeth with closed apex , root canal therapy is recommended due to the extensive loss of tooth structure .
cvek 's vital pulpotomy technique has been used until 1983 with a calcium hydroxide mixture in order to initiate reparative dentin formation by controlling infection and stimulating the wound healing process . in the past decade , mineral trioxide aggregate ( mta ) became popular for maintaining the healing of the pulp tissues as it provides good sealing ability , biocompatibility , and low cytotoxicity and also induces odontoblast to form a hard barrier .
mta was first described in the dental scientific literature in 1993 and was given approval for endodontic use by the us food and drug administration in 1998 . up to 2002 , only one mta material consisting of gray - colored powder was available , and in that year , white mineral trioxide aggregate ( wmta ) was introduced as proroot mta ( dentsply endodontics , tulsa , ok , usa ) to address esthetic concerns .
both formulae contain 75% portland cement , 20% bismuth oxide , and 5% gypsum by weight .
however , few clinical studies exist in the dental literature , showing the success of vital pulpotomy by using mta with long follow - up .
the aim of presenting these case reports is to describe vital pulpotomy treatment with mta in complicated crown fractures of permanent immature anterior teeth in two cases with long - term follow - up .
a 9-year - old boy was referred to the pediatric dentistry clinic with a chief complaint of a trauma that caused fracture in maxillary central incisors by a bicycle accident .
the intraoral examination revealed horizontal mid - crown fractures of his maxillary central incisors with pulp exposure .
the teeth were not mobile and electronic pulp testing showed vital pulpal responses within normal limits .
the radiographic examination revealed that both the teeth had immature apices without any root fracture or periapical radiolucent area [ figure 1a ] .
( a ) preoperative radiograph of case 1 ; ( b ) postoperative radiograph of case 1 ; ( c ) 4.5 years follow - up radiograph showing apical root development a decision was made to perform partial pulpotomies instead of direct pulp capping due to the size of exposure .
it was suggested that the teeth should be treated using wmta ( proroot , dentsply , tulsa dental , ok , usa ) as a partial pulpotomy therapy . under local anesthesia and rubber dam isolation ,
the coronal pulp tissues were gently removed to a depth of 2 mm by using a high - speed sterile round diamond bur ( dentsply maillefer , tulsa , ok , usa ) under water cooling .
hemorrhage was controlled with sterile cotton pellets and sterile saline solution to avoid clot formation .
when pulpal bleeding stopped within 3 min , mta powder was mixed with distilled water according to the recommended consistency and placed without any pressure to cover the exposed pulps .
a moist cotton pellet was placed on the mta and the cavity was sealed temporarily with glass ionomer cement ( fuji ix , gc corporation , tokyo , japan ) .
after 3 days , upper fractured central incisors were reexamined . as the teeth were asymptomatic to percussion sensitivity and gave vital response to electronic pulp test ; permanent composite resin restorations ( z250 , 3m / espe , st .
the patient was followed for 4.5 years with 3-month examination intervals . during this period ,
the clinical and radiographic evaluations of maxillary central incisors presented no spontaneous pain or discomfort to percussion with evidence of continuing apical root development [ figure 1c ] .
an 8-year - old boy was referred to pediatric dental clinic for the treatment of maxillary left central incisor tooth .
the tooth was not mobile and gave a vital pulpal response on electronic pulp testing .
radiographic examination revealed that the maxillary central incisors had open apices and the left maxillary central incisor was fractured .
( a ) preoperative radiograph of case 2 ; ( b ) postoperative radiograph of case 2 ; ( c ) 2 years follow - up radiograph showing apical root development with coronal dentin bridge formation due to the open apices of the maxillary incisors , it was decided to perform vital partial pulpotomy of maxillary left central incisor with wmta .
the patient and his mother were informed about the advantages and possible complications of the treatment plan . upon approval of the patient and his parents , the tooth was treated as in
careful follow - up examinations were done at 3-month intervals in order to observe the root development of left maxillary central incisor . at the 2-years follow - up examination , no problems were detected and periapical radiograph showed that the apex of the maxillary left central incisor tooth was closed without any sign of pathology , and a dentine bridge was apparent at the pulpotomy site [ figure 2c ] .
a 9-year - old boy was referred to the pediatric dentistry clinic with a chief complaint of a trauma that caused fracture in maxillary central incisors by a bicycle accident .
the intraoral examination revealed horizontal mid - crown fractures of his maxillary central incisors with pulp exposure .
the teeth were not mobile and electronic pulp testing showed vital pulpal responses within normal limits .
the radiographic examination revealed that both the teeth had immature apices without any root fracture or periapical radiolucent area [ figure 1a ] .
( a ) preoperative radiograph of case 1 ; ( b ) postoperative radiograph of case 1 ; ( c ) 4.5 years follow - up radiograph showing apical root development a decision was made to perform partial pulpotomies instead of direct pulp capping due to the size of exposure .
it was suggested that the teeth should be treated using wmta ( proroot , dentsply , tulsa dental , ok , usa ) as a partial pulpotomy therapy . under local anesthesia and rubber dam isolation ,
the coronal pulp tissues were gently removed to a depth of 2 mm by using a high - speed sterile round diamond bur ( dentsply maillefer , tulsa , ok , usa ) under water cooling .
hemorrhage was controlled with sterile cotton pellets and sterile saline solution to avoid clot formation .
when pulpal bleeding stopped within 3 min , mta powder was mixed with distilled water according to the recommended consistency and placed without any pressure to cover the exposed pulps .
a moist cotton pellet was placed on the mta and the cavity was sealed temporarily with glass ionomer cement ( fuji ix , gc corporation , tokyo , japan ) .
after 3 days , upper fractured central incisors were reexamined . as the teeth were asymptomatic to percussion sensitivity and gave vital response to electronic pulp test ; permanent composite resin restorations ( z250 , 3m / espe , st .
the patient was followed for 4.5 years with 3-month examination intervals . during this period ,
the clinical and radiographic evaluations of maxillary central incisors presented no spontaneous pain or discomfort to percussion with evidence of continuing apical root development [ figure 1c ] .
an 8-year - old boy was referred to pediatric dental clinic for the treatment of maxillary left central incisor tooth .
the tooth was not mobile and gave a vital pulpal response on electronic pulp testing .
radiographic examination revealed that the maxillary central incisors had open apices and the left maxillary central incisor was fractured .
( a ) preoperative radiograph of case 2 ; ( b ) postoperative radiograph of case 2 ; ( c ) 2 years follow - up radiograph showing apical root development with coronal dentin bridge formation due to the open apices of the maxillary incisors , it was decided to perform vital partial pulpotomy of maxillary left central incisor with wmta .
the patient and his mother were informed about the advantages and possible complications of the treatment plan . upon approval of the patient and his parents , the tooth was treated as in
careful follow - up examinations were done at 3-month intervals in order to observe the root development of left maxillary central incisor . at the 2-years
follow - up examination , no problems were detected and periapical radiograph showed that the apex of the maxillary left central incisor tooth was closed without any sign of pathology , and a dentine bridge was apparent at the pulpotomy site [ figure 2c ] .
in complicated crown fractures , preserving the vital dental pulp or part of it in a healthy state is the main goal in treating young permanent teeth .
it was revealed in several studies that inflammation is confined to the surface 23 mm of the pulp when traumatically exposed and left untreated for up to 168 hours.[1618 ] therefore , it is universally accepted that vital techniques are recommended for immature teeth . for many years , calcium hydroxide has been used in vital pulpotomy to cause a coagulation necrosis , inducing a low - grade irritation that leads to differentiation of the undifferentiated pulp cells .
these cells synthesize predentine which is subsequently mineralized , while the coagulated tissue is calcified .
mta is one of the materials of choice which has been suggested for use in vital pulpotomy treatment , with a reparation mechanism similar to that of calcium hydroxide .
when compared with calcium hydroxide , mta produces significantly more dentinal bridging in a shorter period of time with significantly less inflammation and also provides a hard - setting , non - resorbable surface without the presence of tunnels in the dentine barrier .
therefore , in the cases presented here , wmta was used for the vital pulpotomy treatment .
many in vivo and histological studies have reported the superior physical and biological properties of mta in a short follow - up period.[2125 ] in the cases presented here , after long - term follow - up periods , injured tooth treated with wmta pulpotomy showed successful clinical and radiographical outcomes .
this result should be attributed to excellent sealing ability of wmta to prevent microleakage of bacteria and their by - products .
long - term follow - up of these case reports have shown that vital pulpotomy with wmta would be a successful treatment choice , showing good long - term prognosis for immature teeth with complicated crown fracture .
 this case report describes the partial pulpotomy treatment of complicated crown fractures of two cases by using white mineral trioxide aggregate ( wmta ) with long - term follow - up . in the cases presented here , to injured incisor teeth 
 were open apices and the pulp exposure site was large , so it was decided to perform vital pulpotomy with wmta . 
 long - term follow - up examinations revealed that the treatment preserved pulpal vitality with continued root development and apex formation . 
 wmta may be considered as an alternative option for the treatment of traumatized immature permanent teeth . 
Introduction
Case Reports
Case 1
Case 2
Discussion
Conclusion