Mechanical Pulp Exposure

Dr. Nudera walks through the steps and protocols for vital pulp therapy — specifically apexogenesis — on an 11-year-old patient's mandibular second molar, with long-term follow-up. An 11-year-old with immature roots had a mechanical pulpal exposure during routine caries excavation; the patient was asymptomatic before and remained symptom-free after. Tooth #31 showed a visible pulpal exposure on the mesial aspect, confirmed on periapical, bitewing, and cone-beam imaging. Rather than full root canal therapy — challenging in young teeth with immature, blunderbuss apices and large pulp volumes — vital pulp therapy was chosen to promote continued root development through apexogenesis. After discussion with the parents, direct pulp capping was selected, with future endodontic intervention left open should pathology develop. Under strict aseptic technique and single-tooth rubber dam isolation, all caries and restorative material were removed to sound dentin, the exposure disinfected with 0.5% sodium hypochlorite, and a bioceramic putty placed ~3 mm over the exposure, then etched, primed, bonded, and restored. At the one-year follow-up: successful apexogenesis with continued root development and apical closure, plus a dentinal bridge beneath the bioceramic cap indicating reparative dentin formation — a biologic response that further insulated the pulp and reduced the likelihood of future intervention. A clear example of the healing capacity of vital pulps in young patients, and why vital pulp therapy belongs at the front of the line when managing mechanical exposures in immature permanent teeth.