|Year : 2011 | Volume
| Issue : 1 | Page : 55-57
Regenerative endodontic therapy of non-vital immature maxillary incisors: Working protocol and a case report
AR Pradeep Kumar1, A Subbiya2
1 Department of Conservative Dentistry and Endodontics, Thai Moogambigai Dental College and Hospital, Dr. M.G.R. University, Chennai, India
2 Department of Conservative Dentistry and Endodontics, Sree Balaji Dental College and Hospital, Bharat University, Chennai, India
|Date of Web Publication||4-Mar-2011|
A R Pradeep Kumar
Department of Conservative Dentistry and Endodontics, Thai Moogambigai Dental College and Hospital, Dr. M.G.R. University, Chennai
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This case report describes the treatment of two pulpless immature maxillary central incisors. Conventional apexification techniques were not used. A regenerative technique based on literature to achieve revascularization was followed. This treatment approach involves disinfection of the canal space with topical antibiotics followed by blood clot induction from the periapical tissues. At the one year follow-up, significant root growth was achieved.
Keywords: Immature, pulp, regeneration, revascularization
|How to cite this article:|
Pradeep Kumar A R, Subbiya A. Regenerative endodontic therapy of non-vital immature maxillary incisors: Working protocol and a case report. J Interdiscip Dentistry 2011;1:55-7
|How to cite this URL:|
Pradeep Kumar A R, Subbiya A. Regenerative endodontic therapy of non-vital immature maxillary incisors: Working protocol and a case report. J Interdiscip Dentistry [serial online] 2011 [cited 2020 Jul 3];1:55-7. Available from: http://www.jidonline.com/text.asp?2011/1/1/55/77211
Endodontic treatment of an immature non-vital tooth poses many potential complications. Incomplete root formation with thin dentinal walls and open apices causes difficulty in chemomechanical preparation as well as in obtaining an apical seal. The traditional treatment for such teeth is long-term calcium hydroxide therapy to induce an apical hard tissue barrier. Use of MTA to develop an artificial apical barrier has also been advocated as an alternative method.  These techniques are followed by traditional root filling methods, but they do not increase root wall thickness or root fracture resistance.
Studies on avulsed human teeth  as well as animal studies  have shown evidence of successful revascularization of immature permanent teeth after reimplantation. A number of clinical case reports have also revealed the possibilities that many teeth that traditionally would receive apexification can be treated for apexogenesis. ,,
The potential of root maturation even in the presence of periradicular pathology of endodontic origin has been demonstrated.  A new protocol for the clinical management of these teeth has been presented by Huang,  mainly involving three steps.
- Minimal or no instrumentation.
- Irrigation with 2.5-5.25% NaOCl, 3% hydrogen peroxide and/or peridex.
- Intracanal medication with a paste containing equal parts of metronidazole, minocycline and ciprofloxacin at 20mg/ml.
The purpose of this case report is to add yet another example to the body of dental literature supporting this treatment modality as the treatment option for non-vital immature permanent teeth.
| Case Report|| |
A seven year old boy presented at our private dental clinic in Chennai, India. The patient was accompanied by his mother, who reported that her son had suffered a traumatic injury to the maxillary central incisors about one week ago with loss of coronal fragments. They had visited a dentist who had then proceeded to do a pulpectomy for both the teeth.
The medical history of the child was unremarkable. Clinical examination revealed that both maxillary central incisors had Ellis type III fractures and open access cavity preparations [Figure 1]. The patient was asymptomatic. Percussion, palpation and probing pocket depths were within normal limits. Vitality testing was not done as it may give unreliable results. Radiographic examination showed open apices in all maxillary anterior teeth [Figure 2]. A diagnosis of immature non-vital maxillary central incisors was made.
|Figure 1: Pre-operative photograph showing Ellis type III fracture in maxillary central incisors|
Click here to view
|Figure 2: Pre-operative radiograph showing maxillary anteriors with immature apices|
Click here to view
Under local anesthesia and rubber dam isolation, the access cavities were explored and previous pulpectomy was confirmed. Due to the young age of the patient, it was decided to attempt pulp regeneration rather than traditional apexification.
In the first appointment, minimal instrumentation was done with k-type files taking care to stay within the canal. Irrigation was done with 5% NaOCl and 3% hydrogen peroxide. Next, intracanal medication with antimicrobial agents of equal parts of metronidazole, minocycline and ciprofloxacin in a paste form in the concentration of 20mg/ml was prepared. The paste was placed carefully into the canal, using a lentulo-spiral. The access cavity was sealed with 2 mm thick Cavit as an inner layer and an outer layer of restorative glass ionomer cement (3 mm).
The patient was reviewed after two weeks. The patient was asymptomatic. Under rubber dam, access was gained and irrigation done with hypochlorite and saline. Using a sterile #45 K-file, periapical over instrumentation was done in both teeth to induce bleeding into the canals uptil the CEJ. It was allowed to clot for 15 min and mineral trioxide aggregate (ProRoot MTA, Dentsply) was placed against the clot. The access cavity was sealed with a moist cotton pellet and glass ionomer cement.
After 24 h, the GIC restorations and moist cotton pellets were removed, set of MTA verified and restored with light cure resin [Figure 3].
|Figure 3: Post-operative photograph showing restored maxillary anteriors|
Click here to view
The patient was reviewed after 1, 3 and 12 months and continuous root development was seen radiographically [Figure 4].
|Figure 4: One year post-operative radiograph demonstrating proper root development|
Click here to view
| Discussion|| |
This case demonstrates the potential for revascularization of infected root canal spaces with some form of vital pulp like tissue. Continuous development of the root canal walls and apex was seen.
During apexification, the canal space is filled with Ca(OH) 2 which may not allow ingrowth of vital tissue, thereby leading to a short and weakened root. An alternative treatment of revascularization is preferred. 
Case selection is important. It has been reported that pulp revascularization can occur most predictably in teeth with open apices.  An apical diameter of at least 1 mm (mesiodistally) radiographically is necessary to allow ingrowth of vital tissue.
The presence of a periradicular radiolucency or a negative vitality test are not determining factors in case selection as vital pulp tissue or apical papilla may be present in the canal and at the apex. 
Disinfection and clot formation
Removal of infection from the canal space plays a key role in revascularization. Use of metronidazole, minocycline and ciprofloxacin as intracanal bactericidal medication is effective in reducing endodontic pathogens and in disinfection of the root canal. 
Use of a sterile K-file to penetrate slightly into the periapical tissue will induce hemorrhage into the root canal. This helps in the creation of a blood clot in the disinfected canal space which acts as a matrix for the growth of new tissue.
This new tissue may grow from remnants of pulpal tissue or from the apical papilla which contains stem cells. 
Since this procedure is done on teeth with open apices (no apical constriction), slight over instrumentation can be done without risk of damaging apical root dentine.
MTA was placed carefully over the blood clot. The setting of MTA is not affected by blood.  It is used for its excellent anti-microleakage property and biocompatibility. MTA has been used as a direct pulp capping agent resulting in dentin bridge formation. MTA will take around 3-4 h for initial setting with maturation increasing with time. 
Continuous follow up is necessary. The canal tissue may undergo necrosis necessitating root canal therapy in the future. Calcification of the canal space may also happen.
If revascularization is a failure, traditional treatment options such as apexification using Ca(OH) 2 or MTA remain. However, if revascularization is shown to be predictable, it may well replace traditional treatment modalities for non-vital immature teeth.
| Conclusion|| |
The predictability of this procedure and the type of tissue that is present in the pulp space have to be studied. More clinical research is necessary before a conclusion can be reached. However, the benefit of root growth is so great that pulp regeneration is worth attempting. 
Regenerative endodontics presents a radical shift in the treatment of non-vital immature teeth by apexification to conservation of dental stem cells to allow tissue regeneration and achieve apexogenesis.
| References|| |
|1.||Cotti E, Mereu M, Lusso D. Regenerative treatment of an immature, traumatized tooth with apical periodontitis: report of a case. J Endod 2008 ;34:611-6. |
|2.||Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in 10 therapeutically reimplanted permanent incisors. Endod Dent Traumatol 1986 ;2:83-9. |
|3.||Skoglund A, Tronstad L. Pulpal changes in replanted and autotransplanted immature teeth of dogs. J Endod 1981 ;7:309-16. |
|4.||Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol 2001;17:185-7. |
|5.||Thibodeau B,Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: Case report and review of the literature. Pediatr Dent 2007;29:47-50. |
|6.||George T.-J. Huang. A paradigm shift in endodontic management of immature teeth: conservation of stem cells for regeneration. J Dent 2008;36:379-86. |
|7.||Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang CF. Pulp revascularization of immature teeth with apical periodontitis: a clinical study.J Endod 2009;35:745-9. |
|8.||Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, Kota K, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprofloxacin, metronidazole and minocycline. Int Endod J 1996;29:125-30. |
|9.||Torabinejad M, Higa RK, McKendry DJ, Pitt Ford TR. Dye leakage of four root end filling materials: effects of blood contamination. J Endod 1994;20:159-63. |
|10.||Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: A review of the literature. Dental Materials 2008;24:149-64. |
|11.||Banchs F,Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]