✅ Abstract
This article compares partial pulpotomy and conventional (full/coronal) pulpotomy in primary teeth, focusing on definitions, technique differences, materials, clinical outcomes, and benefits.
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✅ Introduction
Vital pulp therapy in primary teeth aims to preserve radicular pulp vitality, maintain space, and avoid extraction/pulpectomy where possible. The choice between a partial pulpotomy (limited removal of coronal pulp) and a conventional/full pulpotomy (complete removal of coronal pulp) depends on pulp status, exposure etiology (trauma vs caries), clinical signs, and material availability. Recent guideline updates and meta-analyses have refined indications and shown high overall success rates for pulpotomy procedures under appropriate conditions.
✅ Definitions
• Partial pulpotomy (also called Cvek pulpotomy in many contexts): surgical removal of a limited portion (typically ~1–3 mm) of inflamed coronal pulp beneath an exposure, leaving most coronal pulp intact to preserve vitality and promote repair. It is commonly used after traumatic exposures and selected carious exposures when the remaining pulp appears healthy.
• Conventional (full or coronal) pulpotomy: removal of the entire coronal pulp tissue to the level of the canal orifices, followed by placement of a medicament over radicular pulp stumps and definitive coronal restoration. It is widely used for primary molars with carious exposures when radicular pulp is judged capable of healing.
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• Both are forms of vital pulp therapy (VPT) that aim to preserve radicular pulp vitality and avoid pulpectomy or extraction.
• Both require hemostasis, an aseptic technique, and a hermetic coronal seal with a definitive restoration to prevent bacterial leakage.
• Success in both procedures depends on case selection, operator skill, and appropriate post-op follow-up (clinical + radiographic).
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➤ Partial pulpotomy
• Indication: small pulp exposures (trauma is classic indication) or carious exposures when the coronal inflammation is limited and the remaining pulp looks healthy.
• Procedure steps (typical):
1. Remove superficial inflamed pulp tissue ~1–3 mm (or until healthy bleeding tissue encountered).
2. Achieve controlled hemostasis (gentle pressure with saline/sterile cotton; should stop in a few minutes).
3. Place a biocompatible pulp dressing (e.g., MTA, Biodentine, calcium hydroxide, or newer calcium silicate cements).
4. Restore with durable coronal seal (glass ionomer + stainless steel crown or appropriate restoration).
➤ Conventional (full/coronal) pulpotomy
• Indication: deeper carious exposures where coronal pulp is judged inflamed but radicular pulp may still be healthy (commonly used in primary molars).
• Procedure steps (typical):
1. Remove entire coronal pulp down to canal orifices.
2. Achieve hemostasis at canal orifices.
3. Place pulp medicament over radicular stumps (historically formocresol, calcium hydroxide; increasingly MTA, Biodentine, or iRoot/Bioceramics are used).
4. Definitive coronal restoration (often stainless steel crown in primary molars).
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• Calcium hydroxide (CH): traditional agent; can induce reparative dentin but associated with higher internal resorption and lower long-term success in some studies.
• Mineral trioxide aggregate (MTA): strong evidence for higher success and better tissue response than CH in primary molar pulpotomies (less internal resorption, thicker dentinal bridge), though it can cause crown discoloration and is more costly. A randomized trial reported ~94% success for MTA vs ~65% for CH in primary molars (small RCT).
• Biodentine & other calcium-silicate cements: growing evidence suggests comparable outcomes to MTA in many settings and advantages such as improved handling and faster setting in some formulations; recent systematic reviews/meta-analyses have examined these comparisons in primary teeth.
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• Recent meta-analysis/systematic review data indicate high overall success rates for pulpotomy in primary teeth when performed for appropriate indications: pooled 6- and 12-month success rates reported in some reviews exceed 90% under selected conditions. However, heterogeneity in study design, materials, and follow-up remains.
• MTA shows higher success compared with calcium hydroxide in randomized trials of primary molars (example RCT: MTA ~94% vs CH ~65%).
• Partial pulpotomy (when properly indicated, e.g., traumatic exposures or selective carious exposures) demonstrates excellent success in many reports and is increasingly accepted as the conservative option for appropriately selected primary and permanent teeth. Systematic reviews of traumatic exposures report pooled success rates often in the high 80s–90s%.
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➤ Benefits when partial pulpotomy may be preferred
• More conservative: preserves more pulp tissue and potential for continued physiologic function.
• Simpler and quicker: less pulp removal, often easier hemostasis, and preservation of tooth structure.
• High success in traumatic exposures: excellent evidence supports partial pulpotomy after trauma, making it the treatment of choice for many exposed traumatized teeth.
• Lower risk of devitalization-related sequelae: by preserving more vital tissue, risk of certain complications may be reduced if case selection is correct.
➤ Benefits of conventional/full pulpotomy:
• Established for carious exposures in primary molars with extensive coronal pulp involvement when radicular pulp is likely healthy.
• When MTA or modern calcium silicate cements are used, conventional pulpotomy outcomes are excellent and may avoid need for pulpectomy/extraction.
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• Etiology matters: Traumatic exposures often favor partial pulpotomy; carious exposures often lead clinicians to full pulpotomy, although selected carious exposures may be amenable to partial pulpotomy with careful assessment.
• Hemostasis test: inability to achieve hemostasis within a few minutes after pulp amputation suggests deeper inflammation and may indicate need to convert to pulpotomy/pulpectomy or extraction.
• Material selection: current guideline and trial evidence favors bioceramic materials (MTA, Biodentine, iRoot) over CH for better outcomes in many settings. Cost, handling, and esthetic considerations (discoloration with some MTA formulations) should be weighed.
• Seal and restoration: a durable coronal seal (often a stainless steel crown in primary molars) is critical for long-term success.
🦷 Clinical Flowchart: Decision Process — Partial vs. Conventional Pulpotomy in Primary Teeth
| Clinical Step | Assessment or Finding | Recommended Treatment | Key Notes |
|---|---|---|---|
| 1. Initial Diagnosis | No spontaneous pain, normal mobility, no radiolucency | Candidate for vital pulp therapy | Confirm tooth restorable and pulp potentially vital |
| 2. Exposure Etiology | Traumatic pulp exposure with minimal contamination | Partial pulpotomy | Remove 1–3 mm of inflamed tissue; ideal for trauma cases |
| 3. Carious Exposure | Deep caries, small exposure, bleeding easily controlled | Partial pulpotomy or Full pulpotomy | Decision depends on depth of inflammation and hemostasis |
| 4. Hemostasis Evaluation | Bleeding stops within 5 minutes with gentle pressure | Partial pulpotomy | Indicates superficial inflammation and healthy radicular pulp |
| 5. Hemostasis Difficult to Achieve | Bleeding persists beyond 5 minutes or dark blood present | Full pulpotomy | Remove entire coronal pulp to canal orifices |
| 6. Pulp Status After Amputation | Healthy bleeding tissue at orifices | Full pulpotomy | Apply MTA or Biodentine; avoid formocresol |
| 7. Pulp Exposure Size | Small (≤1 mm) | Partial pulpotomy may suffice | Especially if recent exposure and asymptomatic |
| 8. Material Selection | MTA, Biodentine, or bioceramic cement | For both techniques | High biocompatibility, promotes dentin bridge formation |
| 9. Coronal Seal | Immediate restoration with glass ionomer + SSC | Mandatory for both | Ensures long-term success and prevents microleakage |
| 10. Follow-up | Clinical & radiographic check at 6–12 months | Both procedures | Look for absence of symptoms, resorption, or radiolucency |
💬 Discussion
Contemporary evidence (systematic reviews and updated AAPD guidance) supports a broader role of vital pulp therapies in primary teeth than historically believed, with high short- to medium-term success rates when case selection, technique, and materials are appropriate. The AAPD Vital Pulp Therapy guideline (systematic review to July 2022) provides an evidence-based framework for selecting pulpotomy vs other treatments and emphasizes the importance of case selection, asepsis, hemostasis, and a good coronal seal.
While partial pulpotomy is classically favored for traumatic exposures, evidence from meta-analyses indicates it can be an effective conservative option even in some carious exposures — but the clinician must carefully evaluate the extent of inflammation and ability to control bleeding. Conversely, conventional pulpotomy remains a reliable standard for many primary molars with carious exposure, especially when modern bioceramic materials (MTA, Biodentine) are used — these appear to perform better than calcium hydroxide in randomized trials.
Limitations in the evidence base include variability in follow-up duration, outcome definitions, and heterogeneity of materials used across studies. Long-term comparative trials with standardized protocols and longer follow-up would further clarify optimal indications for partial vs full pulpotomy in primary teeth.
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• Both partial and conventional pulpotomy are valid vital pulp therapies for primary teeth when performed with correct indication, aseptic technique, hemostasis, appropriate medicament (increasing evidence for MTA/bioceramics), and a durable coronal seal.
• Partial pulpotomy is more conservative and shows excellent success in traumatic exposures and selected carious cases when the remaining pulp is healthy and hemostasis is achievable.
• Conventional/full pulpotomy, especially when using MTA or Biodentine, provides high success rates for primary molars and may be preferable when coronal pulp removal is required.
• Clinicians should follow current evidence-based guidelines (e.g., AAPD) and apply individualized judgment for each case.
📚 References
✔ American Academy of Pediatric Dentistry. (2024). Vital pulp therapy guideline (Clinical Practice Guideline). Pediatric Dentistry, 46(1). Retrieved from the American Academy of Pediatric Dentistry website.
✔ Lin, G. S. S., Chin, Y. J., Choong, R. S., Wafa, S. W. W. S., Dziaruddin, N., Baharin, F., & Ismail, A. F. (2024). Treatment outcomes of pulpotomy in primary teeth with irreversible pulpitis: A systematic review and meta-analysis. Children, 11, 574. https://doi.org/10.3390/children11050574
✔ Liu, H., Zhou, Q., & Qin, M. (2011). Mineral trioxide aggregate versus calcium hydroxide for pulpotomy in primary molars. Chinese Journal of Dental Research, 14(2), 121–125. (Randomized clinical trial showing higher success with MTA).
✔ Madhumita, S., Chakravarthy, D., Vijayaraja, S., Kumar, A. S., & Kavimalar, D. S. (2022). The outcome of partial pulpotomy in traumatized permanent anterior teeth – a systematic review and meta-analysis. Indian Journal of Dental Research, 33(2), 203–208. DOI:10.4103/ijdr.ijdr_1150_21. (Systematic review supporting high success of partial pulpotomy in traumatic exposures).
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