Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification

AIM

This report addresses the management of a large persistent discharging lesion in an 11-year-old boy. The report describes the use of aspiration-irrigation technique for the management of immature necrotic tooth with persistent discharge after a failed regenerative procedure.

BACKGROUND

Regenerative endodontics aim to provide an increase in root canal width, length, and in apical closure. Alternative procedures, such as apexification, should be attempted when regeneration fails. If the canal cannot be dried to persistent discharge, the aspiration-irrigation technique can be used. The technique relies on using aspiration along with irrigation to remove pus from the periapical area.

CASE DESCRIPTION

This is a case for an 11-year-old patient who had trauma to tooth #11, which resulted in the complicated crown fracture. He had an emergency management that included pulpectomy and intracanal medication at another clinic. Two years later, the patient was presented to our clinic. Upon examination, the diagnosis was previously initiated therapy with asymptomatic apical periodontitis in immature tooth #11. Regeneration was attempted first but failed. The mineral trioxide aggregate (MTA) plug was removed, and the canal had persistent pus discharge. The canal was filled with intracanal medication, and then 2 weeks later, the canal was filled with triple antibiotic paste (TAP). Next visit, and due to continuous discharge, tooth #11 was treated conservatively with an intracanal aspiration-irrigation technique. An IrriFlex needle attached to a high-volume suction was used to aspirate the cystic fluid. Mineral trioxide aggregate plug apexification was performed in a later visit and the tooth was restored.

CONCLUSION

During the 3-month and 16-month follow-up, there was resolution of the symptoms, a decrease in the periapical lesion size, and soft tissues appeared within normal limits.

CLINICAL SIGNIFICANCE

Regenerative procedures are a good option for immature necrotic teeth. These procedures may fail due to persistent pus discharge from the root canals. The aspiration-irrigation technique is a good treatment option in cases of consciously discharging canals. How to cite this article: Alsofi L, Almarzouki S. Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification. J Contemp Dent Pract 2024;25(1):92-97.

Treatment outcomes of immature permanent necrotic evaginated teeth: A retrospective study comparing regenerative endodontic procedures with apexification

BACKGROUND

Few studies have compared the outcomes of regenerative endodontic procedures (REPs) and calcium hydroxide apexification focusing on necrotic teeth with dens evaginatus.

AIM

To qualitatively and quantitatively compare the treatment outcomes of REPs and calcium hydroxide apexification in teeth with dens evaginatus.

DESIGN

Immature permanent necrotic evaginated teeth treated with REPs or calcium hydroxide apexification for a follow-up period of at least 12 months were included. Tooth success and survival rates were analyzed. Changes in radiographic root length, apical diameter, and radiographic root area (RRA) were quantified. Prognostic factors that might influence RRA were identified via multivariate linear regression analysis.

RESULTS

A total of 112 teeth (50 REP cases and 62 apexification cases) with a median follow-up period of 26.5 months were included. Regenerative endodontic procedures and calcium hydroxide apexification exhibited similar satisfactory success and survival rates (p > .05). Additionally, 88 teeth were quantitatively analyzed. The REP group presented a significantly greater percentage increase in RRA and less decrease in apical diameter than the calcium hydroxide apexification group (p < .05). Teeth treated with REPs and with Stages 7 and 8 of root development showed a better gain in RRA (p < .05).

CONCLUSION

While REP and calcium hydroxide apexification had similar success and survival rates, teeth with REPs showed an increase in RRA, indicating that REP is the preferred choice.

Apexification Outcomes in the United States: A Retrospective Cohort Study

INTRODUCTION

This epidemiological analysis used procedure codes from dental insurance claims data to identify apexification cases and evaluate survival at the tooth-level.

METHODS

Dental insurance claims data from New York State (2006-2019) and Massachusetts (2013-2018) were used in an observational, retrospective cohort study to evaluate the provision and treatment outcomes of apexification. Statistical analyses included Kaplan-Meier survival estimates and Cox proportional hazards regression. Cox proportional hazard regression was used to evaluate the hazard of adverse event occurrence by age, gender, tooth type, placement of permanent restoration, and dental provider type. A sensitivity analysis evaluated potential bias in the survival estimates and adjusted hazard ratios (aHRs) due to differential loss to follow-up. Robust standard errors were used to account for potential dependence between teeth within an individual.

RESULTS

The analytic cohort of 575 individuals included 632 teeth, with an average follow-up time of 64 months. The survival rates of apexification procedures were 95% at 1 year; 93% at 2 years; 90% at 3 years; and 86% at 5 years. Tooth retention following apexification was 98% at 1 year; 96% at 2 years; 95% at 3 years; and 90% at 5 years. Tooth type and subsequent placement of a permanent restoration were significant predictors of survival after apexification.

CONCLUSIONS

The procedural and tooth survival outcomes of apexification were high and comparable to studies that analyzed clinical data on tooth survival following apexification.

Long-term Outcome of Endodontically Treated Traumatized Immature Upper Incisors

INTRODUCTION

In a growing child, preservation of traumatized immature permanent upper incisors is challenging. This study aimed to evaluate the long-term outcome of endodontically treated traumatized immature upper incisors and associated variables.

METHODS

A total of 183 traumatized immature upper incisors treated with pulpotomy, apexification, or regenerative endodontic procedure (REP), with follow-up between 4 and 15 years, were assessed for presence of pulpal responses or periodontal/bone responses using standardized clinical and radiologic criteria. Logistic regression, including stage of root development, type and complexity of traumatic event, type of endodontic intervention, and history of orthodontic management, were used to estimate impact on tooth survival and occurrence of tissue responses. Study approved by Ethics Committee Research UZ/KU Leuven (S60597).

RESULTS

After a median follow-up of 7.3 years (interquartile range, 6.1-9.2), 159 teeth (86.9%) were still functional. From these teeth, 58 (36.5%) developed tissue responses. This was significantly associated with stage of root development at moment of trauma (root length <¾) and type of endodontic intervention (REP presenting worst outcome). Tooth loss (24 teeth, 13.1%) occurred after a mean time span of 3.2 years (±1.5) and was significantly associated with type and complexity of the traumatic event and type of endodontic intervention, with apexification showing better results than REP (odds ratio, 0.30; 95% confidence interval, 0.11-0.79).

CONCLUSIONS

A large number of endodontically treated traumatized immature teeth could be kept functional. Very immature teeth, teeth with periodontal tissue damage, and teeth treated with REP were at highest risk for an unfavorable outcome.

Modified pulpotomy procedure in immature permanent teeth with apical periodontitis: a randomised controlled trial

OBJECTIVES

The objective of this study was to evaluate the effectiveness of a modified pulpotomy (MP) procedure in immature permanent teeth with apical periodontitis (AP).

DESIGN

Randomised controlled trial.

SETTING

One public hospital in Shanghai, China PARTICIPANTS: A total of 33 teeth (31 patients) with a definitive diagnosis of AP with radiographic periapical radiolucency were recruited in this study. All the patients (teeth) completed the study accordingly.

METHODS AND INTERVENTION

Patients were randomly assigned to either MP or apexification treatment groups and were followed up for 12 months. Clinical symptoms and complications were recorded, and parallel periapical radiographic images were used to measure changes in root length and apical diameter. Wilcoxon's rank sum test and Fisher's exact test were used to compare the clinical and radiographic outcomes between MP and apexification, and analysed with analysis of variance.

MAIN OUTCOME MEASURE

The primary outcome was increase in root length at 12 months. The secondary outcomes included tooth survival, clinical success and decrease in apical diameter.

RESULTS

MP group showed a significant increase in root length (10.05%±2.14% vs 1.16%±0.79%, p<0.05) at 12 months and a decrease in apical diameter (48.88%±10.42% vs 15.90%±8.88%, p<0.05) as compared with the apexification group. The tooth survival rate was 100%, and 90.91% (30/33) of teeth were asymptomatic with apical healing in both treatment groups (p>0.05).

CONCLUSIONS

MP can be an option for treating immature permanent teeth with AP. MP showed better performance in terms of continued root maturation than apexification. MP and apexification achieved comparable outcomes with regard to the resolution of clinical symptoms and apical healing.

TRIAL REGISTRATION NUMBER

ChiCTR-INR-17012169.

[Comparative study on the effect of microscopic revascularization and apexification in the treatment of pulp necrosis of permanent teeth]

PURPOSE

To compare the curative effect of microscopic revascularization and apexification in the treatment of pulp necrosis of permanent teeth.

METHODS

Seventy-five cases of pulp necrosis in young permanent teeth were divided into two groups according to different treatment methods. Group A (n=30) underwent revascularization under microscope, while group B (n=45) underwent apexification. The treatment effect and pain improvement of the two groups were compared. The changes of the wall thickness and root canal length of the affected teeth before and after treatment were observed, and the bone-like deposition rate after treatment was recorded. SPSS 23.0 software package was used for statistical analysis.

RESULTS

There was no significant difference in the length of root canal between the two groups before treatment (P＞0.05); there was no significant difference in the length of root canal in group B before and after treatment (P＞0.05); the length of root canal in group A was significantly longer than that in group B 6 months after treatment(P＜0.05). There was no significant change in the thickness of root canal wall in group B before and after treatment (P＞0.05). The thickness of root canal in group A was significantly higher than that in group A 6 months after treatment (P＜0.05). Bone-like deposition rate of group A was significantly higher than that of group B 1 month and 6 months after treatment (P＜0.05). The total effective rate of group A and B was 90.00% and 84.44%, the difference was not statistically significant (P＞0.05). The cure rate of group A was 70.00%, which was significantly higher than that of group B (48.89%, P＜0.05).

COCLUSIONS

Microscopic revascularization for pulp necrosis of young permanent teeth can effectively promote root development, lengthen root canal and increase the thickness of canal wall, which is better than apexification.

Orthograde apical plug in a traumatized tooth with necrotic pulp and immature apex using calcium silicate cement: A case report

This case report describes dental management of a 15- year-old boy, undergoing treatment for Thalassaemia Major and Acute Myeloid Leukaemia with bone marrow transplant and immuno-suppressants. During the course of his treatment the patient developed a swelling in anterior maxilla and therefore was referred by the primary physician for evaluation. This case report highlights the management of medically compromised patients in a tertiary care hospital in which apexification was carried out in a permanent immature tooth utilizing MTA as an immediate apical plug.

Management of immature necrotic permanent teeth with regenerative endodontic procedures - a review of literature

Immature necrotic permanent tooth presents a distinctive challenge for the endodontist. Various treatment modalities have been employed to create hard tissue barrier at the apex, which includes non-vital pulp therapy with calcium hydroxide, apexification with mineral trioxide aggregate, pulp revascularisation and regeneration. Regenerative endodontics is a novel modality which involves physiological replacement of the damaged structures of tooth like dentin, root and cells of the pulp-dentin complex. Numerous published case reports have revealed increased dentinal wall thickness, continued root development and apical closure, but there is still lack of sound scientific evidence regarding histological nature of the type of tissue. The current literature review was planned to summarise the evidence regarding the treatment of immature necrotic permanent teeth by regenerative endodontic procedures.

Impact and Fracture Strength of Simulated Immature Teeth Treated with Mineral Trioxide Aggregate Apical Plug and Fiber Post Versus Revascularization

INTRODUCTION

Immature necrotic teeth are at a high risk of fracture, especially at the cervical region, after treatment. This study aimed to compare the impact and fracture strength of immature permanent teeth treated with revascularization versus a mineral trioxide aggregate (MTA) plug and fiber post.

METHODS

This in vitro, experimental study was conducted on 160 maxillary central incisors, which were randomly divided into 10 groups. The groups included a fracture (F) and impact (I) negative control group, F and I positive control groups, F and I MTA groups, F and I revascularizing group, and F and I revascularized groups. Fracture strength was measured using a universal testing machine with a crosshead speed of 1 mm/min. Other tooth samples were then subjected to the Charpy impact test for impact strength measurements, and the amount of energy absorbed by the teeth was determined. Data were analyzed using the Kolmogorov-Smirnov test, analysis of variance, and the Tukey test.

RESULTS

The mean load to fracture of the negative, positive, MTA, revacularizing, and revascularized groups was 1931.8, 1350.1, 1003.8, 1262.5, and 1100.2 N, respectively, and the mean impact strength was 5.04, 3.6, 3.68, 3.16, and 3.65 J, respectively. The fracture and impact strength of the negative control group was significantly higher than that of the other groups (P < .05), but the other groups were not significantly different in this respect (P > .05).

CONCLUSIONS

Despite the limitations of this study, the results showed that none of the tested modalities could significantly increase the impact and fracture strength of simulated immature teeth.

Contemporary endodontic treatment choices for adult patients with dens evaginatus and apical periodontitis: a case report with a 2-year follow-up

Dens evaginatus (DE) frequently leads to pulp exposure and subsequent pulpal inflammation, pulpal necrosis, and periapical inflammation. This case report describes the application of regenerative endodontic therapy and mineral trioxide aggregate (MTA) apexification in a 22-year-old man with mandibular second premolars affected by DE and apical periodontitis. Regenerative endodontic therapy was performed after thorough debridement and placement of calcium hydroxide in the root canal of the left premolar. In contrast, an apical plug of MTA was placed prior to gutta percha compaction in the root canal of the right premolar. Both teeth were restored with adhesive composite resin. A 2-year follow-up examination revealed complete periapical healing.

Six-Year Follow-Up of Immature Tooth Revascularization With Enamel Matrix Proteins

Novel endodontic revascularization techniques have been considered as alternative options for treatment of immature teeth affected by apical periodontitis. The continuous development of the root canal has been recognized as a major advantage of these techniques over traditional apexification approaches. This article reports a case in which endodontic revascularization using extracellular matrix proteins (EMPs) as a scaffold was utilized to treat an immature maxillary lateral incisor with history of trauma and chronic apical periodontitis. The root canal was accessed and sequentially irrigated with sodium hypochlorite (NaOCl) (2 mL, 5.25%), saline solution (10 mL), and gluconate chlorhexidine (10 mL, 0.12%). The root canal was then dried, filled with an antibiotic paste (ciprofloxacin, metronidazole, and minocycline), and sealed for 3 weeks. The antibiotic paste was then removed by irrigating the canal with NaOCl (10 mL, 5.25%). The intracanal scaffold was obtained by injecting a commercially available enamel EMP into the newly formed intracanal blood clot. Mineral trioxide aggregate was used to seal the scaffold in place, and a composite resin restoration was then placed using a universal restorative. At 3 and 72 months, clinical and radiographic analyses demonstrated short- and long-term success of the technique presented. The authors' findings indicate revascularization techniques are promising in the treatment of immature teeth with apical periodontitis. Longitudinal clinical trials are necessary to confirm the findings reported herein.

The sealing ability of ProRoot MTA when placed as an apical barrier using three different techniques: an in-vitro apexification model

OBJECTIVE

To assess the sealing ability of ProRoot MTA when placed as an apical barrier using three different techniques.

METHOD AND MATERIALS

Sixty freshly extracted single-rooted human teeth were decoronated and standardized to a root length of 15 mm. The root segments were prepared with Gates Glidden burs to simulate a divergent open apex of immature teeth and randomly assigned into three experimental groups of 20 samples each. MTA (5 mm) was placed by pluggers (Group A), paper points (Group B), or ultrasonic tips (Group C). A cotton pellet moistened with saline was placed in the root canals till the material set, and the coronal portion was sealed with Cavit. After 24 hours, the Cavit and cotton pellet were removed and the canals dried and obturated with warm guttapercha (Obtura) and AH 26 sealer. Coronal portions of all samples were then sealed with Cavit. All root segments were double-coated with nail varnish except for the open apex and were exposed to methylene blue dye for 48 hours at room temperature. The samples were sectioned longitudinally (layer thickness 0.4 mm) and the extent of dye penetration was measured with a stereomicroscope (magnification 20×).

RESULTS

The mean depth (± standard deviation) of dye leakage for Group A was 1.34 ± 0.5 mm, Group B 1.25 ± 0.4 mm, and Group C 1.14 ± 0.4 mm. There were no significant differences among the three experimental groups (.178 < P < .552).

CONCLUSION

ProRoot MTA has a similar sealing ability when placed as an apical barrier with pluggers, paper points, or ultrasonic tips.

Preliminary Evaluation of Platelet Rich Fibrin-Mediated Tissue Repair in Immature Canine Pulpless Teeth

OBJECTIVE

To evaluate the use of platelet-rich fibrin (PRF) in the regenerative therapy of immature canine permanent teeth.

METHODS

Eight immature premolars of beagle dogs were pulp extracted and cleaned with irrigation, then divided into two groups of empty root canals and those filled with a PRF clot. All of the eight premolars were sealed with mineral trioxide aggregate and glass ionomer cement. Two premolars were left naturally grown as a positive control. The root development was assessed radiographically and histologically after 12 weeks.

RESULTS

The radiological findings showed greater increases in the thickness of lateral dentinal wall in the PRF group than in the vacant group. Histologically, dental-associated mineral tissue, connective tissue, and bone-like mineral tissue grew into the root canals independent of PRF clot use. The PRF was able to increase the thickness of dental-associated mineral tissue. However, the vital tissue differed from the pulp dentin complex.

CONCLUSION

Our study demonstrated the feasibility of using PRF-mediated regenerative therapy in pulpless immature teeth for improving tissue repair.

Apical Closure in Apexification: A Review and Case Report of Apexification Treatment of an Immature Permanent Tooth with Biodentine

Materials such as calcium hydroxide paste and mineral trioxide aggregate are used in apexification treatment of immature permanent teeth, but the search for improved materials with higher characteristics of biocompatibility results in different materials. Biodentine is a tricalcium silicate cement that possesses adequate handling characteristics and acceptable mechanical and bioactivity properties. This report describes the case of a 9-year-old boy who was referred to the Department of Dental Clinic of Querétaro Autonomous University of Mexico. One month prior the patient had suffered a dental trauma of his upper left central incisor and had been treated by another dentist. The clinical diagnosis was previously initiated therapy and symptomatic apical periodontitis. The treatment was apexification with Biodentine. At follow-ups performed at 3, 6, and 18 months after treatment the tooth was asymptomatic. The cone-beam computed tomography scan at 18-month postoperative follow-up revealed continuity of periodontal ligament space, absence of periapical rarefactions, and a thin layer of calcified tissue formed apical to the Biodentine barrier. On the basis of sealing ability and biocompatibility, apexification treatment with Biodentine was applied in the present case report. The favorable clinical and radiographic outcome in this case demonstrated that Biodentine may be an efficient alternative to the conventional apexification materials.

Long-term outcome of MTA apexification in teeth with open apices

OBJECTIVE

This retrospective study aimed to collect information about the long-term outcome of apexification treatment with mineral trioxide aggregate (MTA) of teeth with open apices.

METHOD AND MATERIALS

A total of 98 teeth in 79 patients (m:f = 1:1.3) who had completed endodontic apexification treatment with MTA between September 2005 and January 2014 at a university dental clinic were considered. Both initial treatments and retreatments of former root canal treatments other than apexification were included. All patients were invited for a standardized follow-up visit. Data regarding age, sex, tooth type, reason for treatment, detailed treatment protocol, clinical and radiographic findings, treatment quality, and outcome were also collected from the patients' records. Descriptive statistical analysis was performed.

RESULTS

In the majority of cases, endodontic treatment was related to trauma with fracture (45/98, 45.9%) and luxation injuries (20/98; 20.4%), followed by unknown causes (12/98; 12.2%), retreatments (7/98; 7.1%), hypophosphatasia (7/98; 7.1%), and caries (1/98; 1%). In the beginning, the Periapical Index (PAI) showed pathologic findings with a PAI > 2 in approximately 50% of cases, while 25% presented with minor or an absence of findings. At the end of the observation period, more than 90% showed clinical-radiographic success, whereas eight teeth were associated with an elevated PAI. Only 5% of cases needed further dental treatment, such as root-end surgery or retreatment of the root canal treatment.

CONCLUSION

Within the limits of this retrospective investigation, clinical and clinical-radiographic success of the apexification treatment appears to make this a good and reliable treatment option for teeth with open apices.

Endodontic treatment of trauma-induced necrotic immature teeth using a tricalcium silicate-based bioactive cement. A report of 3 cases with 24-month follow-up

BACKGROUND

Pulp necrosis is the second most common complication after traumatic dental injuries and occurs mostly within the first 6-24 months of follow-up period, depending on the type of dental trauma.

CASE REPORT

Three cases with endodontic treatment scenarios of trauma-induced necrosis in immature permanent anterior teeth. All cases were treated by full canal obturation with Biodentine (Septodont, Saint Maur des Fosses, France) and documented for a follow-up period of 24 months.

CONCLUSION

Copious irrigation of the root canal, minimal mechanical preparation, use of calcium hydroxide for a short period of time and complete obturation of these immature teeth with a bioactive cement with superior mechanical properties such as Biodentine were the prominent reasons attributed to the success of these three cases.

Recombinant Amelogenin Protein Induces Apical Closure and Pulp Regeneration in Open-apex, Nonvital Permanent Canine Teeth

INTRODUCTION

Recombinant DNA-produced amelogenin protein was compared with calcium hydroxide in a study of immature apex closure conducted in 24 young mongrel dogs.

METHODS

Root canals of maxillary and mandibular right premolars (n = 240) were instrumented and left open for 14 days. Canals were cleansed, irrigated, and split equally for treatment with recombinant mouse amelogenin (n = 120) or calcium hydroxide (n = 120).

RESULTS

After 1, 3, and 6 months, the animals were sacrificed and the treated teeth recovered for histologic assessment and immunodetection of protein markers associated with odontogenic cells. After 1 month, amelogenin-treated canals revealed calcified tissue formed at the apical foramen and a pulp chamber containing soft connective tissue and hard tissue; amelogenin-treated canals assessed after 3- and 6-month intervals further included apical tissue functionally attached to bone by a periodontal ligament. In contrast, calcified apical tissue was poorly formed in the calcium hydroxide group, and soft connective tissue within the pulp chamber was not observed.

CONCLUSIONS

The findings from this experimental strategy suggest recombinant amelogenin protein can signal cells to enhance apex formation in nonvital immature teeth and promote soft connective tissue regeneration.

Management of Traumatized Permanent Incisors. Revascularization and Delayed Replantation

This article reports a clinical case of a 9-year-old boy with a traumatic injury to the maxillary central incisors 24 hours after a fall in his schoolyard. The upper left central incisor was avulsed and was kept in saliva for four hours from the moment of trauma until its replantation. The right one was necrotized after one month. We describe successful revascularization treatment of right necrotic immature upper incisor and delayed replantation of left one. After 18 months, radiolucent lesions in the periapical areas of both maxillary central incisors had healed, and root apex development was noted with thickening of the walls in tooth #8.

Current Applications and Future Prospects of Stem Cells in Dentistry

Stem cells are defined as clonogenic, unspecialized cells capable of both selt-renewal and multi-lineage differentiation, contributing to regenerating specific tissues. For years, restorative treatments have exploited the lifelong regenerative potential of dental pulp stem cells to give rise to tertiary dentine, which is therapeutically employed for direct and indirect pulp capping. Current applications of stem cells in endodontic research have revealed their potential to continue root development in necrotic immature teeth and transplanted/replanted teeth. Successful application of pulp revascularization is highlighted here with support of a clinical case report. This article also discusses the role of dental stem cells as a promising tool for regeneration of individual tissue types like dentine, pulp and even an entire functional tooth.

The effectiveness of pulp revascularization in root formation of necrotic immature permanent teeth: A systematic review

OBJECTIVE

The objective of the present study was to carry out a systematic review to analyse the effectiveness of pulp revascularization in the root formation of necrotic immature permanent teeth, as well as the level of scientific evidence regarding this theme.

MATERIALS AND METHODS

The methodology was based on searching electronic databases such as Web of Science, Pubmed, BVS (Medline, Scielo, Lilacs and BBO), Scopus and Cochrane, including manual searches for the references listed in the studies found. The terms used for the literature search were pulp revascularization and endodontics.

RESULTS

Initially, 277 articles were identified from the electronic databases; 17 studies remained after analysis and exclusion of duplicates; exclusion criteria also eliminated six articles; 11 remained for evaluation.

CONCLUSIONS

Although the results found in the present systematic review are relevant, the scientific evidence should be interpreted with caution as the articles report different methods and evaluation parameters. Despite the capacity of the pulp revascularization technique to stimulate the development of the apical closure and thickening of radicular dentin, several aspects still remain unknown, like the key factors of this repair, the type of tissue formed and the long-term prognosis.

Apical plug technique in a calcified immature tooth: a case report

Traumatic injury to an immature tooth may result in pulpal necrosis secondary to pulp canal obliteration, which makes the management of the tooth a clinical challenge for dentists. The present case report describes an innovative apical plug technique with mineral trioxide aggregate in a calcified immature tooth using an ultrasonic tip and long, thin, tapered fissure burs. The technique was proven to be successful clinically and radiographically at 2 years postobturation.

Revascularization of immature, nonvital permanent tooth using platelet-rich fibrin in children

The purpose of this paper was to present a new approach wherein revascularization of the immature, nonvital permanent tooth was performed using platelet-rich fibrin (PRF) as a novel scaffold material. This was performed after disinfection of the root canal space using triple antibiotic paste followed by placing a PRF membrane in the root canal. The patient was followed up regularly at three-, six-, nine-, and 12-month intervals for review. After 12 months, clinical examination showed negative response to percussion and palpation tests but positive response to cold and electric pulp tests. Radiographic examination revealed continued thickening of the root dentinal walls, narrowing of root canal space, root lengthening, and closure of the root apex with normal periradicular architecture. However, more clinical research using large samples is necessary to prove it advantageous for regenerative endodontic therapy in children.

Apexification, apexogenesis and regenerative endodontic procedures: a review of the literature

AIM

Aim of this paper was to present the therapeutical approaches to the management of the immature apex and discuss the evolution of materials and techniques.

METHODS

A Medline search was performed limited to human studies published. The keywords searched were apexogenesis, apexification, pulp regeneration, revascularization.

RESULTS

Apexogenesis and apexification techniques using Calcium hydroxide or MTA give a high succes rate. Recent regeneration procedures may be helpful for apexification in non vital elements.

CONCLUSION

Calcium hydroxide is the gold standard material used in apexogenesis and apexification. New technologies are promoting the growing interest in strategies used for vitality preservation and pulp regeneration.

The plasma-rich in growth factor as a suitable matrix in regenerative endodontics: a case series

The aim of this report is to describe the positive effect of plasma-rich in growth factor (PRGF) on pulp regeneration and apex formation in cases with necrotic pulps and open apices. After access cavity preparation and cleaning of the canal, triple antibiotic paste was inserted into the canals for the purpose of disinfection. After two weeks, apical bleeding was mechanically created by insertion of a #80 file through the apex. PRGF obtained from the patient was centrifuged and injected into the canals up to the level of the cementoenamel junction; the teeth were restored temporarily. The patients returned for review two weeks later. If there was absence of pain, swelling, fistula or any other complication, the teeth were sealed with MTA and composite. At 22 months follow-up, complete apex closure in two teeth and apical closure and continued increase of dentinal wall thickness in two other cases were evident.

Immature permanent teeth with apical periodontitis and abscess treated by regenerative endodontic treatment using calcium hydroxide and MTA: a report of two cases

Regenerative endodontic techniques have been introduced to overcome the limits of the traditional apexification approach and allow continued root development after treatment of infected immature permanent teeth. The purpose of this report was to describe two cases with severe apical periodontitis and abscess that were successfully treated by regenerative endodontic treatment using calcium hydroxide. The report involves treatment of two patients who developed apical periodontitis and abscesses on their immature premolars affected by dens evaginatus. Regenerative endodontic treatment was performed using calcium hydroxide. The treatment procedures have been shown to result in increased thickening of root walls and encourage continued root development. Different outcomes were observed when calcium hydroxide was placed past and within the coronal half of the canal. Calcium hydroxide can be used as an effective medicament in regenerative endodontic technique, and successful regeneration can be expected even in severe cases of apical periodontitis or abscess.

Can we move traumatized teeth?

Dental traumas affect primarily the upper central incisors. The risk is particularly high in cases with protrusive maxillary teeth. Often the trauma will happen in a young patient when the root is not completely formed. With all the complications that can occur on a short-term and also on a long-term, it is legitimate to ask the question of feasibility of orthodontic treatment following a dental trauma. In this article, presenting a clinical case, we will demonstrate that not only is it possible but also that there is a need for orthodontics to minimize the risk of another dental trauma at a later time.

Treatment outcome of mineral trioxide aggregate in open apex teeth

INTRODUCTION

This cohort study is the second phase of a previously reported trial. The primary aim was to assess the outcome of the treatment of teeth with open apices managed by the orthograde placement of mineral trioxide aggregate (MTA) apical plugs. The secondary goal was to identify potential outcome factors for this kind of treatment with a larger sample size and longer follow-up periods than in the first phase of the project.

METHODS

Two hundred twenty-one patients who had been treated between 2000 and 2010 were contacted for follow-up examination 12-128 months after treatment (median, 21 months). At the time of treatment, these patients presented a total of 252 teeth with open apices caused by apical root resorption or excessive apical enlargement or with immature apices. Treatment was performed by supervised undergraduate students (12% of teeth), general dentists (49%), and dentists whose practice was limited to endodontics (39%). The investigated outcome relied on clinical and radiographic criteria and was dichotomized as healed or diseased.

RESULTS

Of 252 examined teeth (88% recall rate), 90% were healed. Teeth with and without preoperative periapical radiolucencies demonstrated healed rates of 85% and 96%, respectively. Forty-five percent of the teeth (113/252) were followed up at least 2 years later and 21% (53/252) at least 4 years later. Univariate survival analyses identified 4 prognostic factors: preoperative apical periodontitis, the experience of the treatment providers, the number of treatment sessions, and the apical extrusion of MTA. Multiple regression analyses confirmed an increased risk of disease for teeth with preoperative apical periodontitis (hazard ratio = 4.59; 95% confidence interval, 1.57-13.4; P = .005). In addition, the experience of the treatment provider was found to influence the outcome (hazard ratio = 0.25; 95% confidence interval, 0.09-0.75; P = .03).

CONCLUSIONS

Orthograde placement of MTA apical plugs appears to be a promising treatment option for teeth with open apices. The healed rates for such teeth were high in this study, even after follow-up periods of more than 4 years. The presence of preoperative apical periodontitis was identified as an important prognostic factor.

[Periapical regeneration. About one case of necrotic immature tooth treated with mineral trioxide aggregate (MTA)]

Therapeutic of apexification with calcium hydroxide has been extensively used in clinical practice, but this technique has some drawbacks (long duration of treatment, weakening of the radicular walls). Different studies have proposed to close the apex opened with MTA (Mineral trioxide Aggregate) which is biocompatible, bacteriostatic, this material induces regeneration of the periapical region through the formation of cementum, bone and periodontal ligament (1, 2). This case report describes the technique of setting up in a single step of the Mineral trioxide Aggregate as an apical barrier for immature permanent roots. This method has allowed us an immediate apical sealing and a root canal filling and a coronary restore permanently as soon as possible. The radiological control confirmed that this type of apexification could be successful with periapical regeneration ad-integrum.

Strategy for apexification of wide-open apex associated with extensive periapical lesion in a weakened root

This case report describes successful apexification for a challenging case involving a 30-year-old man, who suffered from dental trauma involving tooth No. 7 (which had occurred several years earlier) and recently experienced acute periapical abscess in this region. Radiographic analysis revealed incomplete root formation, a wide-open apex, thin root canal walls, and an extensive periapical lesion. Chemomechanical debridement was performed gently using K-files and irrigation with a 1% sodium hypochlorite solution. The root canal was filled with a calcium hydroxide paste, which was replaced periodically. At 18 months post-treatment, an apical barrier tissue and significant reduction of periapical radiolucency were observed; at that time, the entire root canal was filled with gray mineral trioxide aggregate (MTA). At a follow-up 16 months later, the tooth had normal function and periapical repair was complete.

Treatment options: biological basis of regenerative endodontic procedures

Dental trauma occurs frequently in children and often can lead to pulpal necrosis. The occurrence of pulpal necrosis in the permanent but immature tooth represents a challenging clinical situation because the thin and often short roots increase the risk of subsequent fracture. Current approaches for treating the traumatized immature tooth with pulpal necrosis do not reliably achieve the desired clinical outcomes, consisting of healing of apical periodontitis, promotion of continued root development, and restoration of the functional competence of pulpal tissue. An optimal approach for treating the immature permanent tooth with a necrotic pulp would be to regenerate functional pulpal tissue. This review summarizes the current literature supporting a biological rationale for considering regenerative endodontic treatment procedures in treating the immature permanent tooth with pulp necrosis.

Treatment options: apexogenesis and apexification

This article will describe requirements for case selection and review the procedures for apexogenesis and apexification in immature permanent teeth. Nonclinical and clinical data will be presented to support the recommendations, and outcomes will be presented from clinical studies. The dental pulp is an ectomesenchymally derived connective tissue with certain unique properties such as being encased in hard tissues, which limits its collateral circulation. The pulp provides a matrix for binding of its cells and provides support allowing communication between the cells. In addition to immune cells, the dental pulp contains odontoblasts, which are specialized cells capable of producing dentin. In the absence of a vital pulp, dentin deposition is arrested. When an immature tooth is affected by caries or trauma, the pulp requires proper management according to the degree of inflammation and its vitality. Maintenance of pulp vitality will allow continued root development along the entire root length. If the pulp is irreversibly inflamed or necrotic, root-end closure procedures are required when the apex has not fully formed.

Case series: management of immature permanent teeth with pulpal necrosis: a case series

The management of immature permanent teeth with necrotic pulps has changed in recent years from apexification techniques to regenerative endodontic procedures, which enable apexogenesis with physiologic maturation of the roots. This regenerative technique lies squarely in the endodontist's scope of practice, but children presenting with necrotic immature incisors may pose behavior management problems that endodontists are untrained and unwilling to handle. Treatment of these immature permanent teeth provides an excellent opportunity for collaboration and shared patient management between pediatric dentists and endodontists that can yield optimal clinical outcomes. The purpose of this paper was to report a series of 32 regenerative endodontic cases in 28 children treated at the Nationwide Children's Hospital, Columbus, Ohio. The report describes procedural and patient management issues and the need for a collaborative relationship between pediatric dentists and endodontists in tackling these challenging cases.

Open apex type III dens invaginatus: a rare case report of an endodontic retreatment with an anatomical redesign

Dens invaginatus is a critical condition for endodontic treatment. It frequently presents a complex internal anatomy and might be associated with incomplete root and apical development. This article presents one of the few reported cases of endodontic retreatment of Type III dens invaginatus. First, the internal anatomy was modified using burs under an operating microscope. Next, conventional chemical and mechanical preparation with hand files and 2.5% sodium hypochlorite was performed. Finally, an intracanal dressing with calcium hydroxide was used for nine months, at which point the anatomical features in the root canal system could be accessed. Adequate periradicular healing was observed and regression of the lesion was noted at the two-year follow-up. This case reinforces the idea that knowledge about the biologic aspects of endodontics, combined with adherence to technical standards, is helpful in resolving complex cases.

Clinical complications in the revascularization of immature necrotic permanent teeth

The purpose of this case series was to report on the use of a technique of revascularization for necrotic immature permanent teeth, several problems encountered, and solutions to those problems. Eighteen pulp revascularizations were performed in 2009 using the original protocol of revascularization (adapted from the AAE/AAPD joint meeting in 2007 in Chicago). The protocol consisted of opening the canal and disinfecting it with sodium hypochlorite, sealing in a triple antibiotic paste for 2-6 weeks, re-opening, re-irrigating, creating a blood clot in the canal, and sealing with an MTA barrier over the clot. Three problems were encountered during the treatment: (1) bluish discoloration of the crown; (2) failure to produce bleeding; and (3) collapse of the mineral trioxide aggregate (MTA) material into the canal. Modifications to solve these problems included: changing one of the antibiotics, using a local anesthesia without epinephrine, and adding collagen matrix to the blood clot.

Clinical considerations for regenerative endodontic procedures

The management of a tooth with incomplete root maturation and a necrotic pulp is an endodontic and a restorative challenge. Apexification procedures alone leave the tooth in a weakened state and at risk for reinfection. Regenerative endodontic procedures potentially offer advantages, including the possibility of hard tissue deposition and continued root development. Case studies have reported regeneration of human pulplike tissues in vivo, but there is no protocol that reliably regenerates pulplike tissue. This article summarizes historical, current, and future regenerative treatment approaches.

Apical barrier technique with mineral trioxide aggregate using internal matrix: a case report

Apexification is a procedure well recognized and accepted by clinicians and researchers alike. Calcium hydroxide has long been used as an apexification material. The newly developed mineral trioxide aggregate (MTA) has also been shown to be effective in artificial root-end closure. The major problem in cases of a wide open apex is the need to limit the apexification material at the apex, thus avoiding the extrusion of a large amount of material into the periodontal tissue. The use of a matrix is advisable because its placement in the area of bone destruction provides a base on which the sealing material, especially MTA, can be placed and packed. This article presents a case report in which an internal matrix was formed using absorbable collagen sponge to provide a base for MTA placement at the apex.

Biologically based treatment of immature permanent teeth with pulpal necrosis: a case series

This case series reports the outcomes of 8 patients (ages 9-4 years) who presented with 9 immature permanent teeth with pulpal necrosis and apical periodontitis. During treatment, 5 of the teeth were found to have at least some residual vital tissue remaining in the root canal systems. After NaOCI irrigation and medication with ciprofloxacin, metronidazole, and minocycline, these teeth were sealed with mineral trioxide aggregate and restored. The other group of 4 teeth had no evidence of any residual vital pulp tissue. This second group of teeth was treated with NaOCl irrigation and medicated with ciprofloxacin, metronidazole, and minocycline followed by a revascularization procedure adopted from the trauma literature (bleeding evoked to form an intracanal blood clot). In both groups of patients, there was evidence of satisfactory postoperative clinical outcomes (1-5 years); the patients were asymptomatic, no sinus tracts were evident, apical periodontitis was resolved, and there was radiographic evidence of continuing thickness of dentinal walls, apical closure, or increased root length.

Review of the success of pulp exposure treatment of cariously and traumatically exposed pulps in immature permanent incisors and molars

The decision to retain immature permanent tooth with pulp disease is problematical. Restoring the tooth would normally involve some form of pulp capping/pulpotomy procedure or a more radical pulpectomy and root canal treatment. Pulp capping/pulpotomy procedures, where all or part of the pulp is retained, relies upon an accurate assessment of the pulp condition, and the careful management of the remaining healthy tissue. Pulpectomy or root canal treatment is technically difficult as the root apex is open with the result that conventional preparation and filling techniques are compromised. On the other hand, the inappropriate extraction of immature teeth with pulp disease will result in immediate aesthetic and functional difficulties that may require the patient to have orthodontic or restorative care that will have potential life-long implications, e. g. removable or fixed prosthesis. The aim of this article is to provide an overview of the aetiology of pulp disease in immature teeth and to review current evidence of the outcome of conservative pulp treatment.

Fragment reattachment associated with pulpotomy in a posterior tooth with incomplete root formation

This article reports a case of preserving pulp vitality combined with aesthetics and functional reconstruction of an immature permanent molar extensively destroyed because of a carious lesion. After a pulpotomy using calcium hydroxide, the tooth crown was restored by bonding a dental fragment obtained from an extracted tooth from another individual. Aspects of diagnosis and treatment that directly affect the prognosis of the techniques are discussed. Radiographic and clinical follow-up for two years showed complete root development and a very satisfactory restoration with regard to aesthetics and function.

The coming era of regenerative endodontics: what an endodontist needs to know

Recently, two new clinical concepts have emerged for the management of endodontically compromised immature permanent teeth. One involves a revitalization approach to achieve tissue generation and regeneration in the root canal system. In this method, new living tissue is expected to form in the cleaned canal space allowing continued root development in terms of both length and thickness. The other is the active pursuit of pulp/dentine regeneration via tissue engineering technology to implant or re-grow pulps. Although the technology is still at its infancy, it has potential to benefit immature pulpless teeth by allowing continued growth and maturation. Evidence has shown that using dental stem cells, pulp and dentin can be regenerated in the root canal space. It is foreseeable that a decade or two from now, regenerative endodontics is likely to be an alternative treatment modality for clinical endodontics. It is therefore important for us to understand stem cells and tissue regeneration and be prepared for this clinical practice.

Obturation of immature non-vital tooth using MTA. Case report

The purpose of this report was to present the treatment of an immature necrotic permanent mandibular second molar using mineral trioxide aggregate (MTA) as an orthograde root filling. In such cases, the canal remains large, with thin and fragile walls, and the apex architecture remains divergent. This case demonstrates the efficacy of MTA in this particular situation as an effective material to support regeneration of apical tissue in immature necrotic teeth. The treated tooth was asymptomatic. At the one-year follow-up, there were no clinical symptoms, but there was radiographic healing of periradicular tissues and new hard-tissue formation in the apical area of the affected tooth.

Continued root-end growth and apexification using a calcium hydroxide and iodoform paste (Metapex®): three case reports

AIM

The aim of these case reports is to present a treatment to promote root-end growth and apexification in nonvital immature permanent teeth in children.

METHODS AND MATERIALS

Three cases were presented where the calcium hydroxide and iodoform paste Metapex® was placed in the root canals of immature permanent teeth using disposable plastic tips. The teeth involved were evaluated radiographically at regular intervals for the first 12 months after placement of the paste. At the end of 12 months all the cases showed continued root growth and apical closure (apexification) with no evidence of periapical pathology. Conventional endodontic treatment was then performed.

RESULTS

In all three of the clinical cases presented, a combination of calcium hydroxide and iodoform paste (Metapex®) was used and showed promising results in inducing root-end growth and closure after 12 months.

CONCLUSION

In these three clinical cases, the calcium hydroxide and iodoform paste Metapex® (Meta Biomed Co. Ltd., South Korea) was found to induce apical closure when assessed radiographically. Over a period of 12 months all the cases showed continued root growth.

CLINICAL SIGNIFICANCE

The calcium hydroxide and iodoform paste Metapex® promoted continued root-end growth with apexification in the nonvital immature permanent teeth treated.

Evolution of apical formation on immature necrotic permanent teeth

PURPOSE

To evaluate the evolution of apical formation on 28 necrotic immature permanent teeth treated with calcium hydroxide at different stages of root development.

METHODS

Apical formation in 28 necrotic incisors was carried out (27 upper and one lower incisors), in children between the ages of 6 and 13 years old (11 males, 10 females). Following anesthesia and rubber dam isolation, the chamber was opened and the coronal and root pulp tissue was removed. Next, after measuring the canal, the root canal was irrigated with 5% sodium hypochlorite. Once the canal was dried, it was filled with the CaOH2 powder mixed with physiologic saline solution to a dense consistency but malleable. This paste was compressed into the canal using a cotton pellet. The canal was completely filled up to the apex. Finally, the cavity opening was sealed with zinc oxide-eugenol (IRM) and glass-ionomer (Vitrebond). Follow-up appointments were made every 3 months in order to evaluate the evolution of the periapical radiolucency and the formation of the apical barrier.

RESULTS

The duration of the apical induction was 8.6 +/- 5.36 months. Increase or lack of growth in the length of the root canal and the type of root end closing was as follows: cementoid tissue (85.72%); osseous tissue (14.28%), with a 100% overall success rate. The evolution of these teeth was monitored over a 2-year period with re-infections occurring in 7.1 percent of the cases.

Apexogenesis treatment with a new endodontic cement: a case report

INTRODUCTION

This article describes an apexogenesis report of an 8-year old boy referred to our clinic 4 weeks after an impact trauma to the maxillary left central incisor that caused a complicated crown fracture and pulpal exposure.

METHODS

In the radiographic examination, the tooth was observed to be immature. After access cavity preparation, cervical pulpotomy was performed, and the remaining pulp was capped with calcium enriched mixture (CEM) cement. The crown was restored by using the fractured incisal segment on the next day.

RESULTS

The radiographic and clinical examinations on the 6-month and 12-month follow-ups showed that the tooth remained functional, root development was completed, and the apex was formed. A calcified bridge was produced underneath the capping material. No further endodontic intervention was necessary.

CONCLUSIONS

Considering the healing potential of traumatized immature vital pulp, the use of CEM cement for apexogenesis might be an applicable choice; however, further clinical studies with longer follow-up periods are recommended.

A report on the clinical and radiographic outcomes of 38 cases of apexification with mineral trioxide aggregate

The aim of the study was to report on the clinical and radiographic assessment of 38 cases of apexification using MTA over a three year period. Thirty-eight cases of immaturely developed teeth requiring endodontic therapy were treated using MTA to achieve an apical barrier prior to obturation with gutta-percha. The teeth were clinically and radiographically assessed. The findings indicate that apexification using MTA is a predictable procedure. In particular, the number of visits and the total time taken to achieve an apical barrier was markedly less than conventional techniques using calcium hydroxide. The presence of a preoperative periapical radiolucency had no effect on the outcome. MTA shows promise as a viable alternative to calcium hydroxide to achieve root-end closure and using MTA, the number of visits to achieve a successful apical barrier may be markedly reduced. The presence of preoperative periapical radiolucencies did not affect the outcome or the treatment protocol.

Treatment options for teeth with open apices and apical periodontitis

Three clinical cases involving teeth with open apices and apical periodontitis were treated using different protocols. The first case was managed with intracanal calcium hydroxide paste for 12 months before obturation with gutta-percha and sealer. In the second case, an apical plug of mineral trioxide aggregate (MTA) was used before obturation with gutta-percha and sealer and treatment was completed during 2 appointments. In the third case, the tooth, which had a divergent root canal system, was completely obturated with MTA and treatment was also completed over 2 appointments. In all 3 cases, signs of bone healing were observed after treatment.

[A comparison of the effect between Vitapex paste and antibiotic paste in apexification.]

PURPOSE

To study the effects of two root canal filling material in the apexification.

METHODS

172 juvenile permanent teeth,including 62 teeth with pulpitis, 32 teeth with necrotic pulp and 78 teeth with periapical periodontitis, were divided into two groups.The root canal was filled with Vitapex paste and antibiotic paste.Every patient was examined once three months.The treatment lasted 6-30 months.The outcome of treatment was investigated for three years following treatment.

RESULTS

The effective rate in the group of Vitapex paste and antibiotic paste group were 86.0% and 91.9% (P>0.05).In periapical periodontitis group,the effective rate of antibiotic paste group was significantly higher than the other (P<0.05).

CONCLUSION

Both Vitapex paste and antibiotics paste were good filling materials in apexification. Antibiotic paste was better than the other in periapical periodontitis group.