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Cvek pulpotomy: Report of a case

with five-year follow-up
~aziye Sari, DDS, PhD

L.aumatic
injury is a cornmon cause of pulpal damage
in anterior teeth. Crown fractures with pulp exposure
represents 18 percent to 20 percen.t of tr~~~tic
~juries
that involve the teeth. The majonty of IDJunes IDvolve
recently erupted or young permanent teeth with immature roots, and for that reason everything possible should
be done to maintain the pulpal vitality.1,2 Treatment preserving the pulpal function allows root development.
Any increase in root development
in a young tooth
strengthens the tooth and increases the likelihood of
retention. In addition, a tooth with incomplete root formation is a poor candidate for root canal treatment. Most
of these teeth will be lost due to subsequent trauma or
simply the forces of mastication.3 Camp asserted that
almost all of these young, endodontically involved teeth
have a good blood supply and there is almost always
vital tissue in the apical third of the canal which cannot
be removed with currently used chemicals.4 For these
reasons, pulp capping and pulpotomy ren:~ .va~uable

techniques when immature incisors sustam illJunes resulting in exposure of coronal pulp tissue.
The present report describes the successful tre~~ent
by Cvek pulpotomy of a traumatized permanent. ~clsor
tooth. This tooth was subsequently followed clinically
and radiographically
for five years.

Dr. Sari is a Research Assistant, Department of Pedodontics, Faculty

of Dentistry University of Ankara, Turkey.

CASE REPORT
A six-year-old boy was seen in the Department of Pediatric Dentistry of the Dental Faculty of Ankara U~versity (Turkey) sixteen hours after a fall from a bl~ycle.
The incident resulted in the fracture of both maxillary
central incisors. After the accident, the patient was
treated in a private dental office where the fractured te~th
were dressed with calcium hydroxide ( CaOH) and zmc
oxide-eugenol (ZOE) cement. The temporary restoration
in the left central incisor was completely lost after one
hour. Intraoral examination revealed pulp exposure of
the maxillary left central incisor and ZOE restoration in
the maxillary right central incisor. Both maxillary central incisors had sustained enamel-dentin fractures. The
fractured central incisors were not mobile. Periapical
radiographic examination showed that the apices of the
incisors were incomplete. There was no evidence of fractures involving root or alveolar bone (Figure 1).
There was positive response to electric pulp testing in
both of the maxillary central incisors as well as adjacent
teeth. It was decided to perform a Cvek Pulpotomy on
the exposed left central incisor tooth. After a~ini~~ation of a local anesthetic (Citanest-Astra;
SodertolJe,
Sweden) and isolation with cotton rolls, the crown was
cleaned with iodine solution, and the pulp was amputated to a depth of 1-2 rom within dentin with a spoon
excavator. Bleeding was controlled by flushing with a
sterile saline solution to avoid clot formation. CaOH2
powder mixed with distilled water was applied over

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JOURNAL OF DENTISTRY FOR CHILDREN

Figure 2. Periapical radiograph of applied CaOH2 for maxillary

left central incisor.
Figure 1. Periapical radiograph of left central incisor with complicated crown fracture (pulp/dentin exposure) in six-year-old boy
sixteen hours after trauma.

the pulp wound with a sterile port-amalgam. The cavity was sealed with ZOE (Figure 2). The other central
incisor tooth was restored with a composite resin. The
patient was told not to use his maxillary incisors to eat
with the exception of soft foods.
Clinical and radiographical evaluations of the maxillary left central incisor were carried out at three months,
six months, twelve months, and yearly up to five years
after the Cvek pulpotomy. The treatment was considered clinically successful at follow-up if the treated tooth
showed:
No history of pain
No swelling or sinus tract
No history of thermal sensitivity
No tenderness to percussion
The pulpotomy was considered radiographically successful at follow-up if the radiographs showed:
No loss of lamina dura
No loss of trabecular bone
No internal resorption
Continued root development
Dentin bridge formation

Figure 3. Periapical radiograph at three months

pulpotomy. Dentin bridge is clearly seen.

after Cvek

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SARI

CVEK PULPOTOMY

Figure 4. Incisal view of left central incisor. A hard tissue barrier

was observed clinically.

Three months after treatment, the tooth was clinically

symptomless and radiographically, a hard tissue barrier
was present (Figure 3).The temporary filling and CaOH2
were removed with a small spoon excavator and a hard
tissue barrier was observed clinically (Figure 4). The
cavity was covered with a CaOH2 cement, and the restoration was completed with a glass ionomer cement
and a composite resin material (Figure 5).
Three years post pulpal treatment, it was seen that
the apex of the tooth was closed (Figure 6 ) and by the
end of five years, the tooth remained clinically and
radiographically symptomless (Figure 7).

Figure 5. Intraoral view of completed

maxillary left central incisor.

composite restoration of

DISCUSSION
Pulp capping and pulpotomy are the treatments of
choice for injured teeth with vital, exposed pulps and
with open apices. These treatment techniques involve
the same procedure but differ at the level at which the
procedure is done.4 Direct pulp capping has some disadvantages when compared with pulpotomy:
Direct pulp capping should not be done in the
presence of a blood clot.5-8
Pulpotomy provides better retention of the
dressing material and possible surgical control of
the wound.9
The time between the trauma and the treatment
must be short in direct pulp capping.2,4
In partial pulpotomy, the exposure time is a secondary factor because the well vascularized pulp tissue has
the ability to produce a defense reaction to resist bacterial contamination.lOn Also, Cvek showed that an
exposed pulp in a young tooth with an open apex can

Figure 6. Periapical radiograph at three years after pulpotomy; apex

of tooth was closed.

remain viable for up to three weeks.9 Cvek and Lundberg

found that in teeth with open apices that remained
exposed up to three weeks, by removing 1-3 rnm of the
surface pulp, viable tissue was present.12 This allowed a
vital procedure to be done predictably. Five years post-

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JOURNAL OF DENTISTRY FOR CHILDREN

dentin thereby increasing the risk of cervical fracture.15,16

In addition, Cvek at al asserted that partial pulpotomy
is conservative of tooth tissue, thus facilitating subsequent restoration of a fractured crown.15
Camp concluded that if Cvek pulpotomy was carried
out correctly, the canal would not be calcified or sclerosed, and would have a dentinal bridge; root formation
would continue.4 The same results were seen in the
present case. Camp also asserted that if pulpal pathology did occur, root canal therapy was still an option.
CONCLUSION
The present report demonstrates the clinical and radiographic success of the Cvek pulpotomy technique five
years following treatment.
REFERENCES

Figure 7. Periapical radiograph at five years after Cvek pulpotomy;

there were no pathologic changes.

pulp therapy, the pulp tissue was extirpated and examined histologically. All the specimens had healthy,
uninfected, non-inflamed pulp tissue. This uniform
response strongly indicated that this procedure could
be done without resulting in calcification in the root
canals. In contrast, for years the endodontic community
had said that if a pulp capping or pulpotomy was done,
the pulp was diseased and caused sclerosis that resulted
in pulp degeneration and calcificmetamorphosis.4 However, Camp asserted that the major reason for calcific
metamorphosis problems in pulpotomies was the level
at which they are done (at the cementoenamel junction
or deeper-cervical pulpotomy ).4 These procedures need
to done in the line of vision so that the practitioner can
control the procedure and visualize each step. If CaOH2
gets into the pulp, it is picked up by the circulation and
spreads throughout the pulp. Where a molecule of CH
contacts pulpal tissue, calcification results. Meticulous
control of the procedure restricts diffusion of the CaOH2,
thus controlling calcification.4
The other advantages of Cvek pulpotomy versus
Cervical pulpotomy are in the preservation of cell-rich
coronal pulp tissue, (a necessary element for better healing) forming a dentin bridge and in the physiologic
apposition of dentin in the coronal area.913,14 In contrast,
cervical pulpotomy removes all the coronal pulp, leaving the crown without the physiologic apposition of

1. Andreasen, J.O,:Challenges in clinical dental traumatology. Endod

Dent Traumatol, 1:45-55,February 1985.
2. Blanco, LP.: Treatment of crown fractures with pulp exposure.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 82:564-568,
November 1996.
3. Camp, HJ.: Pediatric endodontic treatment. In: Cohens, Burns,
R.C, editors. Pathways of the pulp, 6th ed. St. Louis: c.w. Mosby
Co, 1994.
4. Camp, J.H: Management of trauma in child and adolescent.
Pediatr Dent, 17: 379-383, September-November 1995.
5. Tronstad, 1.; Mjar, Y.A.:Capping of the inflamed pulp. Oral Surg
Oral Med Oral Oral Pathol, 34:477-485, September 1972.
6. Fuks, A.B.; Bielak, S.; Chosak, A.: A clinical and radiographic
assessment of direct pulp capping and pulpotomy in young permanent teeth. Pediatr Dent, 4:240-244, May-June 1982.
7, Lirnm, K.c.; Kirr, E.E.J.: Direct pulp capping: A review. Endod
Dent Traumatol, 3:213-219, October 1987,
8. Stanley, H.R.: Pulp capping: Conserving the dental pulp. Oral
Surg Oral Med Oral Pathol, 68:628-639,November 1989.
9. Cvek, M.: A clinical report on partial pulpotomy and capping
with calcium hydroxide in permanent incisors with complicated
crown fracture. J Endod, 4:232-237, May 1978.
10. Jontel, M.; Bergenholtz, G.; Scheynius, A. et al: Immunocompetent cells in the normal dental pulp. J Dent Res, 66:1l49-1153,September 1987.
11. Trowbridge, H.O.: Immunological aspects of chronic inflamation
and repair. J Endod, 16:54-61,January 1990.
12. Cvek, M. and Lundberg, M.: Histological appearance of pulps
after exposure by a crown fracture, partial pulpotomy, and clinical diagnosis of healing. J Endod, 9:8-11,January 1983.
13, Avery, J.: Repair potential of the pulp. J Endod, 7:205-212, April
1981.
14. Fuks, A.B.;Chosak, A.; Klein, H. et al: Partial pulpotomy as a treatment alternative for exposed pulps in crown-fractured permanent incisors. Endod Dent Traumatol, 3:100-102,April 1987.
15. Cvek, M.; Cleaton Jones, P.; Austin, P. et al: Pulp reactions to
exposure after experimental crown fractures or grinding in adult
monkeys. J Endod, 8:391-397,August 1982.
16. Cvek, M.: Partial pulpotomy in crown-fractured incisors: Results
3 to 15years after treatment. Acta Stomatol Croat, 27:167-173,1993.