JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 86-89

Regenerative endodontic treatment for necrotic immature permanent premolar: A report of case

1 Department of Conservative Dentistry and Endodontics, Maratha Mandal Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belgavi, Karnataka, India
2 Postgraduate Student, Maratha Mandal Dental Collage, Belgavi, Karnataka, India

Date of Web Publication21-Dec-2017

Correspondence Address:
Dr. Sheetal B Ghivari
4A, Basav Colony, Bauxite Road, Nehru Nagar, Belgaum, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_2_17

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Regenerative endodontic procedures provide new hope of converting nonvital tooth into vital once again. These potential regenerative approaches include root canal revascularization, postnatal stem-cell therapy, pulp implant, scaffold implant, three-dimensional cell printing, injectable scaffolds, and gene therapy. In this article, we describe successful revascularization treatment of necrotic permanent premolar tooth. Clinical and radiographic examination showed pulp involvement due to deep pit defect and periapical infection. Examination findings suggested revascularization treatment which was started with irrigation of canals using 1.25% of sodium hypochlorite and saline, followed by placement of 3-week dressing of triple antibiotic paste (ciprofloxacin, metronidazole, and minocycline). After removal of triple antibiotic paste blood clot was induced and mineral trioxide aggregate was placed on the blood clot followed by sealing the canal with glass ionomer cement. During radiographic and clinical follow-ups, the patient was asymptomatic and periapical lesion was healed, roots continued to develop, and root apex maturogenesis was complete.

Keywords: Immature apex, maturogenesis, mineral trioxide aggregate, revascularization

How to cite this article:
Ghivari SB, Khanchandani D, Jamadar A. Regenerative endodontic treatment for necrotic immature permanent premolar: A report of case. J Int Clin Dent Res Organ 2017;9:86-9

How to cite this URL:
Ghivari SB, Khanchandani D, Jamadar A. Regenerative endodontic treatment for necrotic immature permanent premolar: A report of case. J Int Clin Dent Res Organ [serial online] 2017 [cited 2019 Dec 13];9:86-9. Available from: http://www.jicdro.org/text.asp?2017/9/2/86/221392

   Introduction Top

Treatment of necrotic immature teeth with apical periodontitis (AP) is a great challenge to endodontists. Conventionally practiced treatment modalities for these teeth are calcium hydroxide-based apexification and apexogenesis.[1] Although this approach is predictable, long-term use of calcium hydroxide is associated with multiple treatment appointments, frequent recontamination, root canal wall brittleness, and increased risk of cervical root fracture.[2]

Alternative treatment options for these teeth are immediate placement of mineral trioxide aggregate (MTA) apical plug. These treatment modalities often resolve signs and symptoms of pathosis but less beneficial for continued root development, normal pulp nociception, and immune defense.[3] Immature open apex tooth has a rich blood supply and contains stem cells which has a potential to regenerate damaged tissue. Therefore, immature teeth with open apex should be treated as conservatively as possible to allow apexogenesis to occur.[4]

Revascularization is a regenerative treatment modality and biological procedure designed to physiologically replace damaged tooth structure including dentin and root structure. Regenerative endodontics comprises research in adult stem cells, growth factors, organ tissue culture, and tissue engineering materials.[5] Different populations of adult stem cells are isolated in oral tissues; these are dental pulp stem cells, stem cells from exfoliated deciduous teeth (SHED), stem cells from apical papilla (SCAP), periodontal ligament stem cells, and tooth germ progenitor cells. Stem cells of apical papilla are capable of forming odontoblast-like cells, producing dentin in vivo and are likely to be source of primary odontoblasts for formation of root dentin.[6]

SCAP cells residing in the apical papilla survive even in necrotic conditions because of their proximity to vasculature of the periapical tissues. Once thorough root canal disinfection is achieved, the surviving cells of epithelial root sheath of Hertwig (SCAP) can generate primary odontoblast and complete root formation.[7] A retrospective study evaluated the long-term survival of the teeth treated with regenerative endodontic procedures (REPs), a 100% survival rate was found for REPs, 95% for MTA apexification, and 77% for calcium hydroxide apexification.[8]

Thus, the aim of this article is to report a successful maturogenesis of permanent necrotic premolar by revascularization approach.

   Case Report Top

A 19-year-old male reported to the department of conservative dentistry and endodontics with a chief complaint of draining sinus [Figure 1]. On clinical examination, sinus tract was found in the buccal sulcus with respect to 35. The tooth was intact without any carious involvement, but on exploring with dental explorer, a pit defect was found. On detailed clinical examination, tooth was not tender to percussion and there was no periodontal pocket found. Radiographic examination revealed an immature apex with periapical lesion and one of the pulp horns appears to extend to the occlusal level [Figure 2]. A provisional diagnosis of chronic periapical abscess was made.
Figure 1: preoperative picture

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Figure 2: preoperative radiograph

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After explaining the treatment procedure, informed consent was obtained from the patient. In the first visit, after administering local anesthesia (2% lignocaine without adrenaline) under rubber dam isolation, access cavity was prepared. Working length determination was done using no. 20 K-file [Figure 3]. Root canal debridement was done using 1.25% sodium hypochlorite (NaOCl) and saline. A mixture of ciprofloxacin, metronidazole, and minocycline (1:1:1), i.e., triple antibiotic paste (TAP) was prepared in lower concentration to prevent stem cell toxicity (0.01–0.1 mg/ml) and these lower concentrations appear as a liquid form. The liquid was carried carefully in the canal with syringe and the access cavity was sealed with glass ionomer cement (GIC).
Figure 3: working length determination

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After 3–4 weeks, the patient was recalled for the second visit. The sinus tract was healed completely and soft tissue swelling resolved. Tooth was anesthetized with 2% lignocaine without vasoconstrictor and isolated under rubber dam. The TAP was removed from the canal using slow alternate irrigation using sterile saline solution and 20 ml 17% ethylenediaminetetraacetic acid (EDTA) using a similar close-end needles. The root canal was dried with paper points, and bleeding was created by overinstrumentation using no. 30 K-file beyond the apex, till 3 mm below the cementoenamel junction (CEJ) [Figure 4]. After 2 min, when clot was formed, 3–4 mm of MTA was placed and sealed with GIC and composite resin restoration [Figure 5].
Figure 4: after inducing bleeding

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Figure 5: post-MTA placement

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The patient was recalled at 6, 12, 18, and 24 months, clinical and radiographic examination was done. After 6-month recall, partial resolution of periapical lesion was found. At 12-month recall, complete healing of periapical lesion was observed and periapical bone was completely regenerated [Figure 6]. In the same radiograph, there was increased root canal wall thickening, root length was increased, and apex was partially closed. At 24-month recall along with increase in the root length and width, the root apex maturogenesis was completed. The pulp vitality of the tooth was evaluated by heat and cold test and it was supplemented with electric pulp test. The patient responded positively for both the thermal tests and to very low level of electric current.
Figure 6: 12-month follow-up radiograph

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   Discussion Top

REPs have emerged as a clinical alternative for the treatment of immature teeth with pulpal necrosis. Several case-dependent factors may influence the outcome of REPs such as pulpal necrosis due to trauma, developmental anomalies, or caries. The most common etiological factor for pulpal necrosis in published case reports is the presence of dental developmental anomalies accounting for 25% of all cases. The periapical status such as size of periradicular lesion, presence of an abscess, and duration and intensity of the chief complaint are some of the possible modifiers of the treatment outcome.[8]

Approximately 40% of all cases treated with REPs were diagnosed with AP including 31% symptomatic AP and 9% with asymptomatic AP. Furthermore, approximately 35% presented with an apical abscess (12% acute and 23% chronic). Thus, most of the teeth being treated with a REP have well-established AP or an abscess.[9]

Treatment of REPs includes minimal to no mechanical debridement, and choices of chemical agents and intracanal medicaments were done based on their bactericidal and bacteriostatic properties with least harm to stem cells and growth factors. NaOCl at a concentration of 6% has a profound negative effect on stem cell survival and differentiation, whereas 17% EDTA partially reverses the detrimental effects of NaOCl and promotes the survival and differentiation of stem cells present in apical papilla (SCAP). In the present case report, irrigation regimen of 1.25% NaOCl followed by irrigation with 17% EDTA was followed.[10]

Use of antibiotic formulations as endodontic medicaments had been documented many decades before, an antibiotic mixture composed of ciprofloxacin, metronidazole, and minocycline known as TAP or 3 mix has been most widely used in REPs.[11] The drug is mixed with saline, water, or propylene glycol until a thick creamy consistency was obtained. To prevent unwanted side effects or toxicity, the drugs should be used in their therapeutic window. REPs are stem cell-based therapies wherein stem cells should survive disinfection protocols to participate in tissue regeneration. A concentration of 100 μg/ml of each drug was sufficient to eradicate bacteria from root canals and has least effect on survival of stem cells.[12]

Creating a blood clot in REPs is a challenging procedure, insufficient bleeding has been reported when epinephrine-containing local anesthetics have been used. As an alternative, local anesthetic without epinephrine or mepivacaine (3%) can be used during the second visit followed by laceration of apical papilla with hand file. However, care should be employed not to extend laterally and apically to injure Hertwig's epithelial root sheath which plays an important role in root development. Adequate placement of MTA over the blood clot formed is a common challenge encountered in REPs. To avoid staining of MTA and provide adequate strength at the cervical region, MTA is often placed below the CEJ or even in the middle third of the root canal.[13]

Importantly, the pulpal healing capacity appears to be directly dependent on the stage of root development or the diameter of apical foramen with greater healing observed with apical foramina more than 1.5 mm.[14] For conventional root canal therapy, absence of signs and symptoms of pathosis and radiographic healing are considered to be successful outcome of the treatment. For REPs, resolution of pathosis, radiographic evidence of healing, and continued root development were considered as successful outcome of the treatment. A retrospective study evaluated the long-term survival of the teeth treated with REPs, a 100% survival rate was found for REPs, 95% for MTA apexification, and 77% for calcium hydroxide apexification.[8]

Although REPs have addressed immediate clinical need, the nature of tissue formed in teeth undergoing these procedures remains controversial. More advanced bioengineering approaches including scaffold growth factor matrix and chemokine-based cell homing may be required to achieve predictable regeneration of a functional pulp-like tissue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Chueh LH, Ho YC, Kuo TC, Lai WH, Chen YH, Chiang CP. Regenerative endodontic treatment for necrotic immature permanent teeth. J Endod 2009;35:160-4.  Back to cited text no. 1
Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol 2002;18:134-7.  Back to cited text no. 2
Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: A review and report of two cases with a new biomaterial. J Endod 2011;37:562-7.  Back to cited text no. 3
Chueh LH, Huang GT. Immature teeth with periradicular periodontitis or abscess undergoing apexogenesis: A paradigm shift. J Endod 2006;32:1205-13.  Back to cited text no. 4
Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: A review of current status and a call for action. J Endod 2007;33:377-90.  Back to cited text no. 5
Bansal R, Jain A, Mittal S. Current overview on challenges in regenerative endodontics. J Conserv Dent 2015;18:1-6.  Back to cited text no. 6
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Saber SE. Tissue engineering in endodontics. J Oral Sci 2009;51:495-507.  Back to cited text no. 7
Shin SY, Albert JS, Mortman RE. One step pulp revascularization treatment of an immature permanent tooth with chronic apical abscess: A case report. Int Endod J 2009;42:1118-26.  Back to cited text no. 8
Diogenes A, Henry MA, Teixeira FB, Hargreaves KM. An update on clinical regenerative endodontics. Endod Topics 2013;28:2-23.  Back to cited text no. 9
Galler KM, D'Souza RN, Federlin M, Cavender AC, Hartgerink JD, Hecker S, et al. Dentin conditioning codetermines cell fate in regenerative endodontics. J Endod 2011;37:1536-41.  Back to cited text no. 10
Sato T, Hoshino E, Uematsu H, Noda T.In vitro antimicrobial susceptibility to combinations of drugs on bacteria from carious and endodontic lesions of human deciduous teeth. Oral Microbiol Immunol 1993;8:172-6.  Back to cited text no. 11
Takushige T, Cruz EV, Asgor Moral A, Hoshino E. Endodontic treatment of primary teeth using a combination of antibacterial drugs. Int Endod J 2004;37:132-8.  Back to cited text no. 12
Sonoyama W, Liu Y, Yamaza T, Tuan RS, Wang S, Shi S, et al. Characterization of the apical papilla and its residing stem cells from human immature permanent teeth: A pilot study. J Endod 2008;34:166-71.  Back to cited text no. 13
Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endod Dent Traumatol 1986;2:83-9.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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