step-by-step pulpotomy technique


A thorough pre-operative assessment should be carried out by taking a good history, clinical examination and radiographs.






Step I: Administer local analgesia with the use of a topical analgesic
Figure 1  :  It is essential to achieve profound analgesia. This would usually mean an inferior dental nerve block for lower teeth and an infiltration for the upper teeth   For lower primary molars, in addition to a nerve block (a), a buccal infiltration (b) should always be given to anaesthetize the long buccal nerve for the placement of the rubber dam clamp.


 

   

 Figure 1





Step 2: Isolate tooth with rubber dam
Figure   2 :   This shows 75 isolated with a rubber dam. This is important to prevent any further con­tamination of the pulp, to aid patient comfort and to prevent leakage of formocresol onto the soft tissues.


Figure   2


    

Step 3: Remove caries and determine site of pulp exposure
Figure  3  : It is important to remove all visible caries before the pulp chamber is entered, otherwise bleeding from the pulp will make visualization of caries difficult. It is also necessary to determine the exposure site (arrow), since it is easier to gain access to the pulp chamber through the exposure.


Figure  3




Step 4: Remove roof of pulp chamber
Figure 4 : The bur is placed in the exposure, and the site is widened until the whole of the roof of die chamber is removed. If there is no apparent exposure, the cavity is made deeper until a 'dip' is felt, when the bur passes through the roof into the void of the pulp chamber. Once the pulp chamber has been entered, the bur is not taken any deeper but is moved sideways to remove die roof of the chamber (a). Haemorrhage from the pulp will be evident at this stage (b).

 
Figure 4




Step 5: Remove coronal pulp with a large excavator or a large round bur
Figure  5 :   A large excavator is preferred to remove the coronal pulp tissue (a). When a round bur is used, care muse be taken that it is only moved lightly along the floor of the pulp chamber. Any excessive pressure can result in perforation of the floor and failure of the pulpotomy (b. c). After removal of the inflamed coronal tissue, the haemorrhage into the cavity should be reduced (d).







 

 


   Figure 5

  


Step 6: Apply formocresol on a pledget of cotton wool for four minutes
Figure  6 : A small pledget of cotton wool is dipped in formocresol and squeezed in a piece of gauze to remove excess (a) before it is placed in the pulp chamber for four minutes (b).

 
Figure  6

   

Step 7: Remove formocresol pledget after four minutes and check that the haemorrhage has stopped
Figure  7  Continued bleeding from the root canal tissue signifies inflammation of the radicular tissue. If this occurs the pulp should be extirpated and a pulpec-tomy performed as described in Section B of this chapter.





Figure  7





Step 8: Fill pulp chamber with cement
Figure  8  When the arrested, the pulp chamber proprietary brands of zinc Kalzinol.
haemorrhage has been is filled with one of the oxide eugenol. 
    


   
Figure  8

   
Step 9: Restore the tooth with a stainless steel crown
Figure  9  The final restoration of any pulp-treated tooth should always be a stainless steel crown (Chapter 5). This is to provide protection to the tooth weakened by the removal of a large amount of tooth tissue as required for pulp therapy.

 

 
Figure  9

Step I0: Talee a postoperative radiograph
Figure  10  A post-operative peri-apicat radiograph should show the zinc oxide eugenol filling condensed adequately in the pulp chamber of 75 and preferably completely obliterating the openings of the root canals: (a) pre-operative; (b) immediately post-operative.



   


      Figure  10


 
 
Follow-up
Teerh that have undergone pulpotomy should be regularly reviewed both clinically and radiographi-cally at follow-up visits, preferably 6-monthly. Peri­apical radiographs or good bitewings that allow visualization of the furcation area should be taken.
Appearance of rarefaction of the bone in the furca­tion area or a worsening of the bone condition in the furcation usually signifies failure of the proce­dure. A decision is then made to either extract the tooth, carry out a pulpectomy or observe for a few months, on the basis of other clinical considerations such as behaviour and space requirements.

Figure  11  A series of follow-up radiographs after a pulpotomy was carried out on 75: (a) pre-operative; (b) immediately post-operative; (c) three months; (d) 12 months. There has been no deterioration of the bone in the bifurcation region, an indication of success.





      

  

    

 
Figure  11











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