Vital pulp therapy : an alternative to root maturation of a tooth with superficial micro abscess

Maintenance of pulp functional integrity should be aimed by the treatment of trauma affected immature permanent teeth. The prognosis of vital pulp therapies (VPT), when well indicated and correctly performed, not only preserves pulp vitality but also provides the immature root development. This case reports the treatment of a patient with a crown fractured immature maxillary right central incisor. Clinical examination, radiographic inspection and sensitivity tests confirmed tooth vitality. In spite of the superficial micro abscess presence, pulpotomy was the treatment of choice according to the pulp vitality characteristics found during the undergoing surgery. Root development and apical closure were verified at the 1 year radiographic control. After 3 years of follow-up, even with the occurrence of 3 new traumatisms, the treated tooth showed radiographic sound characteristics. Nevertheless, on the fourth-year return, the conventional endodontic treatment had to be carried out due to radiographic signal of initial root obliteration. It was concluded that pulp vitality diagnosis step and clinical-radiographic follow-up are extremely important for the pulpotomy outcome. This conservative approach resulted in success since it induced root development and apical closure, permitting the posterior execution of the endodontic therapy.

The vital pulp therapy (VPT) is a conservative treatment that aims to promote the healing of pulp tissue and the formation of hard tissue to preserve pulp vitality (Cvek, 1978;Haikal et al., 2020;Çaliskan & Güneri. 2017) and whenever possible this therapy is the treatment of choice for immature complicated crown fractures (Nosrat et al., 2013;Chueh et al., 2009;Garcia-Godoy & Murray, 2012;Eppa et al., 2018). The VPT can only be carried out on vital teeth which do not have spontaneous pain, extreme reaction to percussion tests nor mobility (Witherspoon et al., 2006;Cohenca et al., 2007); displaying normal radiographic characteristics in the periapex and in the dental periodontum (Svizero et al.,2003). There has been some controversy about VPT durability, while some researches consider it a definitive treatment (Fuks et al., 1993;Robertson et al., 1996;Rafter, 2005), others recommend a conventional root canal filling after tooth complete apical foramen formation to prevent calcific degeneration and obliteration of the pulp canal (Cvek, 1978;Bergenholtz & Spångberg, 2004). In spite of this disagreement, the VPT has demonstrated satisfactory results on root maturation, even better than pulp revascularization treatment (Forghani et al., 2013).
The purpose of this case report is to highlight the pulp vitality diagnosis importance on the conservative pulp approach, describing a pulpotomy treatment as a strategy to the root apical sealing of an incompletely developed permanent tooth with exposed pulp and superficial micro abscess.

Methodology
This article consists of a description of a clinical case. The work was not submitted to the ethics committee, since it is a case report in which the procedure performed was not experimental. A free and informed consent form was signed by the patient's parents about the procedures performed and the use of images. Research, Society and Development, v. 9, n. 12, e40891211351, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i12.11351 5

Case Report
An 8-year-old-male patient searched for treatment 30 days after suffering a sportrelated traumatic dental injury. The patient anamnesis reported that he did not have any pain symptoms and went to a community health center three days after the accident, where glass ionomer cement was applied on the dental fracture.
Clinical examination revealed an enamel-dentin crown fracture on the left central incisor ( Figure 1A). The sensitivity tooth tests of percussion, palpation and temperature (Endo Ice -Hygenic, Akron, OH) resulted in a positive answer. The radiography ( Figure 1B) confirmed the presence of an immature apex, with normal periapical and periodontal conditions.
As soon as the emergency dressing was removed, a micro abscess sprang out the surface of the exposed pulp ( Figure 1C). Even though this micro-abscess was found during the undergoing surgery, pulpotomy was the treatment of choice due to positive response to the sensitivity tests, absence of spontaneous pain and radiographic normal periapical conditions. After local anesthesia the rubber dam isolation was done. Then, coronal opening and pulp surgical excision were carried out with a high speed sterile diamond. The total pulpotomy was done, so the removal of inflamed pulp tissue extended to the level of the crown cervical third (4 mm of depth). At this moment, clinical pulp characteristics that indicate the pulpotomy technique were recognized: adequate pulp bleeding of a bright reddish color with easy hemostasis and a consistent pulp radicular remainder ( Figure 1D). The hemostasis was obtained through the pulp compression with a cotton ball soaked in sterile saline. As long as the pulp bleeding was controlled, a steroid-antibiotic combination (Otosporin® -Glaxo-Wellcome Pharma, Vienna, Austria) was applied on the pulp stump for 10 minutes (Figure 2A). Subsequently, the cavity was lined with a paste of calcium hydroxide (Biodinâmica Química e Farmacêutica, Ibiporã, Brazil - Figure 2B), sealed with a calcium hydroxide cement (Hydro C® -Dentsply, São Paulo, Brazil), (Figure 2C), and provisionally restored with glass ionomer cement (Vitro-Fil LC® -DFL, Rio de Janeiro, Brazil - Figure   2D). Research, Society and Development, v. 9, n. 12, e40891211351, 2020 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v9i12.11351