MANAGEMENT OF NON VITAL IMMATURE TEETH

DEFINITIONS

IMMATURE TOOTH: A tooth which has been erupted in the oral cavity but still has incompletely

formed root/roots i.e. roots short in length than normal with thin dentinal walls and open apical

foramen. a. normal Recently erupted tooth

b. abnormally Immature due to pathology

NONVITAL TOOTH a tooth which is tested negative to normal pulp vitality tests i.e. tooth

with necrosed pulp.

TOOTH DEVELOPMENT REVIEW

Tooth is a unique structure developed via interactions between dental epithelium and

mesoderm. From the formation of dental lamina in epithelium, tooth develops in sequential

stages including bud, cap, early bell, late bell stages. The dental lamina induces the

underlying ectomesenchyme to form the dental papilla. At the cap stage, entire tooth organ is

surrounded by dental follicle made of mesenchymal cells. At the early bell stage, the dental

epithelium is stratified and the junction where inner and outer epithelium meet is termed as

cervical loop, which play an important role in root development.

Odontoblast diffentiated from mesenchymal cells of dental papilla produce dentin in late bell

stage. As the coronal dentin encases dental papilla, it evolves to dental pulp. During this stage

crown is developed followed by root development as the epithelial cells from cervical loop

proliferate apically and influence the differentiation of odontoblasts from dental papilla and

cementoblasts from follicle mesenchyme. The apically extending two layered epithelial wall

forms the hertwig s epithelial root sheeth (HERS) which plays an important role in

determining the shape of root. The epithelial diaphragm surrounds the apical opening of the
pulp and eventually becomes apical foramen. When the first layer of dentin has been laid

down, HERS begins to disintegrate leaving behind discontinued epithelial rests of Mallasez

in periodontal ligament.

Apical papilla is the dental papilla located at the apex of developing permanent teeth, is

loosely attached to the developing root. It is located apical to the epithelial diaphragm and

separated from pulp by apical cell rich zone. Because of the apical location, this tissue may

be benefitted by its collateral circulation that enables it to survive during process of pulp

necrosis.

Nolla stages of tooth developement

Generally, roots are halfway to two third formed at the time of eruption with wide open

apices and pulp volume is still large with thin dentinal walls. Three more years after tooth

eruption are normally needed for the further deposition of dentin and maturation of apex but

during this time, tooth is susceptible to trauma and caries invasion, both of which may

threaten the viability and functionality of cells involved in root development. Damage of the

pulp, apical papilla, and /or the HERS resulting in cell death impedes root formation.

ETIOLOGY OF PULPAL NECROSIS: Permanent teeth erupt and undergo root maturation

between 6 – 18 years of age in a sequential manner. Any factors that impinge on the vitality

of pulp may interfere with the completion of root development. Two main reasons are:

A. Trauma:

 mainly affect anterior teeth.

 30 % children are affected by injuries to young permanent teeth.

B. Caries

 Mainly affects posterior teeth.

 First molars erupt around 6-7 years of age ahen oral hyagine is difficult to maintain

DIAGNOSIS OF PULPAL NECROSIS:

Popular tests such as heat, cold, electric pulp test remain the main tool to distinguish between

vital and non vital pulp. Limitations:

 not 100% accurate (accuracy 86 % with cold test, 71% for heat and 81% for electric

pulp test.)- (Petersson et al 1999)

 Pulp necrosis is a progressive process and there is no close correlation between results

of these tests and histological condition of pulp. A negative response to these does not
 necessarily means that pulp is totally non vital but a positive response can predict that

there is some vital pulp present.

 Furthermore, these tests rely on nerve supply of teeth for response which is

complicated by the fact that in immature teeth, the sensory plexus of nerves is not

well developed and not that all pulpal nerves end among odontoblasts or into

predentin or into dentin as compared to mature teeth in occlusion. (Fuss et al 1986)

Advanced endodontic diagnostic aids such as pulp oximetry, laser doppler flowmetry, dual

wavelength spectroscopy have been shown to be promising but these are very costly and not

available at most of the places.

So, history, clinical examination, radiographic examination plays an important role in

diagnosis.

 History of trauma and its duration.

 History of pain, its duration and characteristics.

 Clinical examination of coronal color change is important. Pink discoloration

indicates increased vascularity of pulp which can resolve to normal after few days in

absence of infection. Persistant discoloration, particularly shift to gray, indicates

necrotic changes in pulp probably due to bacterial contamination.

 Presence of swelling, sinus tract, tenderness on percussion is more indicative of pulp

necrosis followed by periapical changes.

 Radiographic indicators of non vitality include a widened PDL space, periapical

radiolucency associated with tooth, arrested root development as compared to normal

counterpart (short root, thin dentinal walls, wide open apex).

 Also, it is helpful to make final diagnosis after the tooth is accessed and pulp is

observed directly.
SEQUELAE OF NON VITAL TOOTH:

Once diagnosed that the immature tooth in question is non vital (may be asymptomatic at that

time), its management is definitely recommended as:

 Root development is arrested and leaving the tooth with short roots having thin

dentinal walls increases its susceptibility to fracture. Also, crown root ratio is not

favourable mostly.

 Necrotic pulp in root canals is either already infected or it may later be contaminated

by bacteria entering the canal through cervical tooth defects, along root root canal

walls or through blood (anachoretic contamination). Then these contaminated necrotic

pulp can irritate periapical tissues leading to periapical abcess, granuloma or may be

cyst formation over a longer period of time.

DIFFICULITIES IN ENDODONTIC MANAGEMENT OF IMMATURE TEETH:

The immature root with a necrotic pulp presents multiple challenges to successful treatment:

 The infected root canal space cannot be disinfected with the standard root canal

protocol with the aggressive use of endodontic files. Mechanical cleaning with

instruments that remove dentin is contraindicated, because it may further weaken the

already thin root canal walls.

 Once the microbial phase of the treatment is complete, Obturation of the root canal is

difficult, even for the experienced clinician because the open apex provides no barrier

for stopping the root filling material before impinging on the periodontal tissues.

 Even when the challenges described earlier are overcome, the roots of these teeth are

thin with a higher susceptibility to fracture.

The frequency of cervical root fractures was markedly higher in endodontically treated

immature teeth than in mature teeth and ranged in incidence from 28%–77%, in accordance

with the stage of root development. This finding emphasized the importance of preserving

pulp vitality of the immature teeth involved in dental trauma or deep caries. –Cvek (1992)

TREATMENT OPTIONS:

1. Traditional method – calcium hydroxide apexification

2. Modified traditional method – MTA apical plug technique

3. Novel method involving regenerative endodontics- pulp revascularization

Apexification is inducing a calcific barrier at the open apex. Teeth receiving apexification

normally gain only an apical hard tissue bridge without a further development of the root. It

differs from apexogenesis with vital pulp therapy in which develop a normal thickness of

dentin, root length and apical morphology.

CALCIUM HYDROXIDE APEXIFICATION

History: B. W. Hermann first introduced calcium hydroxide in dentistry as a biologic

dressing for pulp capping to preserve pulp vitality in 1920s.

Kaiser first reported the use of calcium hydroxide for apexification in 1964 and the technique

was popularized by the work of Alfred L. Frank (1966), so known as FRANK’ S procedure.

Rationale:

Use of calcium hydroxide is to achieve healing of periradicular tissues and formation of a

hard tissue barrier against which adequate root filling can be placed. The desired effects have

been shown to occur with high predictability in large no. of clinical and experimental studies.
Properties of calcium hydroxide rendering its use as an apexification material

1. Biocompatibility

2. Strong antibacterial effect all related to its high pH that is 12.5.

3. Solvent action

4. stimulation of hard tissue formation

A) Antibacterial effect:-

In vitro studies have shown that 99.9% of common root canal flora were killed within a few

minutes of direct contact with calcium hydroxide, E.faecalis appearently show some

resistance but ultimately were killed within 24 hrs of contact. So, very few bacteria can be

cultivated from infected root canals after 1-4 weeks of Ca(OH)2 dressings.

Several bacterial species are unable to survive in the highly alkaline environment.

Antimicrobial activity is related to the release of hydroxyl ions. To be effective against

bacteria located inside the dentinal tubules, the hydroxyl ions from calcium hydroxide should

diffuse into dentine at sufficient concentrations. The hydroxyl ions cause:

 Damage to the bacterial cytoplasmic membrane: lipid peroxidation by OH- ions

 Protein Denaturation leading to loss of bacterial enzyme activity necessory for

metabolism

 Damage to the DNA: Hydroxyl ions induce splitting of the strands of DNA. DNA

replication is inhibited.

 Ability of calcium hydroxide to absorb carbon dioxide may contribute to its

antibacterial activity.
ALSO, Physical barrier: Ca(OH)2 Intracanal medicament also act as a physicochemical

barrier, precluding the proliferation of residual microorganisms and preventing the

reinfection of the root canal by bacteria from the oral cavity.

B) Calcium hydroxide has capacity to dissolve necrotic pulp remnants, related to its alkaline

pH and caustic action, rendering root canal walls clean. This is important for treatment of

immature teeth, in which intensive reaming to clean dentinal walls is contraindicated.

C) When in contact with the vital tissue in apical area, calcium hydroxide induces hard tissue

formation by reactions similar to those in coronal pulp in pulp capping or pulpotomy; only

difference being formation of reparative or cementum like tissue instead of dentin indicating

involvement of periapical tissues in barrier formation rather than pulpal odontoblasts.

Mechanism: when placed in contact with vital tissues, pure Ca(OH)2 causes a tissue necrosis

(app. 1- 1.5 mm in depth), consisting of several layers with a layer of firm coagulative

necrosis in contact with vital tissue. This layer act as a low grade irritant that stimulate the

periapical tissues to form a hard tissue barrier in defence. Calcium hydroxide does not

become incorporated in the mineralized repair tissue, which derives its mineral content solely

from the dental pulp, presumably via the blood supply. These observations indicate that

calcium hydroxide is an initiator rather than a substrate for repair.

So, calcium hydroxide has limited chemical role in hard tissue formation by exerting a low

grade irritation either directly or through coagulative necrosis. Also, the antimicrobial effect

of calcium hydroxide allows the body’s repair reactions to act uninterruptedly.

The high pH may also activate alkaline phosphate activity, which is postulated to play an

important role in hard tissue formation.

Technique:
1. Rubber dam isolation: the affected tooth is isolated with rubber dam. In case of intruded or

fractured teeth, a palatal gingivectomy is recommended to allow adaptation of rubber dam

and provide access into root canals. In cases of partial eruption or splinted teeth where rubber

dam can-not be applied, the solutions which do not harm tha oral mucosa should be used for

disinfection.

2. Access cavity and working length: it is important to avoid placing the instrument through

the apex, which might injure the epithelial diaphragm.

3. Chemo mechanical debridement: remnants of necrotic pulp are removed with barbed

broaches and files, in a careful and methodological manner using moderate lateral pressure

and vertical movements to avoid weakening of root canal walls, along with copious irrigation

using 0.5% NaOCl and saline. It is important that vital tissue present in apical part of pulp

lumen should not be removed as this may improve the quality and speed of apical bridging or

provide further root development.

4. Root canal is dried with large sterile paper points.

5. Ensure that there are no signs and symptoms of active infection such as tenderness on

percussion that contraindicate the sealing of the canal space.

6. A thick paste of calcium hydroxide mixed with camphorated mono para

chlorophenol(CMCP) or in methylcellulose paste is filled in root canal with help of amalgam

carrier ar lentulo spiral. Due to toxicity and lack of any additional benefits, the mixing of

calcium hydroxide with CMCP or with corticosteroids or antibiotics is not recommended

now. Instead calcium hydroxide mixed with sterile saline or with anaesthetic solution gives

equally good results. After filling, it is compressed with a cotton pellet towards the apex in

order to ensure contact with vital tissue apically. Excess of material should not be forced into
periapical tissues; though it will be resorbed readily but it can carry necrotic pulp remnants

into periapical area that can cause an acute exacerbation of choronic periapicl inflammation.

This step is followed by backfilling with calcium hydroxide to completely fill the canal thus

ensuring a bacteria-free canal with little chance of reinfection during the 6 to 18 months

required for the hard tissue formation at the apex. When a radiograph is taken, the canal

should seem to have become calcified, indicating that the entire canal has been filled with the

calcium hydroxide.

7. The calcium hydroxide is meticulously removed from the access cavity to the level of the

root orifices, and a well-sealing temporary filling is placed.

8. Follow ups:

At 3 months interval a radiograph is taken to evaluate if a hard tissue barrier has formed, if a

periapical healing occurred and if the calcium hydroxide has washed out of the canal.This is

assessed to have occurred if the canal can be seen again radiographically. If calcium

hydroxide washout is seen, it is replaced as before. If no washout is evident, it can be left

intact for another 3 months. Excessive calcium hydroxide dressing changes should be

avoided if possible because the initial toxicity of the material is believed to delay healing.

However, some studies do say that repeated change of calcium hydroxide resulted in more

rapid formation of hard tissue barrier. Repeated filling is often needed in cases with large

apical radiolucency because calcium hydroxide that comes in contact with vital tissue capable

of hard tissue formation only after resolution of periapical destruction.

9. Obturation:

Depending upon the width of apical foramen and size of periapical lesion, it may take 6-18

months for apical barrier to form. After this, a gentle obturation technique is used to fill the
root canal. The tip of the master GP point is heat softened and gently pressed against the hard

tissue barrier, followed by lateral condensation with accessory GP points.

Thermo-plasticized GP or vertical condensation method can also be used for obturation.

PROGNOSIS:

The success of this technique has been reported in 79 – 96% of all treated teeth in various

clinical studies. However, there are few disadvantages with this technique:

a) Long treatment time - it typically takes between 6 and 24 months for the body to form the

hard tissue barrier (average 18 months).

b) Patient compliance - The patient needs to report every 3 months to evaluate whether the

calcium hydroxide has washed out and/or the barrier is complete enough to provide a stop to

a filling material. This requires patient compliance for up to 6 visits before the procedure is

completed.

c) Susceptibility to fracture - It has also been shown that the use of calcium hydroxide,

especially in long term therapies, due to denaturation and dissolution of its protein contents,

increases the brittleness and risk of cervical root fracture. Thus it is common for the patient to

sustain another injury and also fracture the root before the hard tissue barrier is formed.

MTA APICAL PLUG TECHNIQUE

MTA was developed by Mahmoud Torabinejad at Loma Linda University, California, USA

in the 1990s as a root-end filling material. The first literature about the material appeared in

1993 and has been approved by the U.S. Food and Drug Administration in the year 1998.

Over the years, further research on the material has resulted in MTA being applied in various

clinical situations in addition to its use as a suitable root-end filling material.

Torabinejad and Chivian suggested MTA apical plug as an alternative to Ca(OH)2

apexification.

Properties of mta rendering its use as an apical plug in immature teeth

 Biocompatiblity

 Excellent marginal sealing ability

 Easy manipulation

 Induction of hard tissue formation; though MTA can itself act as an apical barrier,

against which permanent obturation can be placed, when used in immature teeth.

 Promotes apical healing

Mechanism of action

When MTA is placed in direct contact with human tissues, it

 Forms CH that releases calcium ions for cell attachment and proliferation ,

 Creates an antibacterial environment by its alkaline pH (10.5-12.5)

 Modulates cytokine production

 Encourages differentiation and migration of hard tissue– producing cells

 The reason for MTA’s resistance to bacterial penetration is its tight physical

adaptation of MTA to adjacent dentin that includes penetration into dentinal tubules.

Technique

1. Rubber dam isolation: the affected tooth is isolated with rubber dam. In case of intruded or

fractured teeth, a palatal gingivectomy is recommended to allow adaptation of rubber dam

and provide access into root canals. In cases of partial eruption or splinted teeth where
rubber dam can not be applied, the solutions which do not harm tha oral mucosa should be

used for disinfection.

2. Access cavity and working length: it is important to avoid placing the instrument through

the apex, which might injure the epithelial diaphragm.

3. Chemo mechanical debridement: remnants of necrotic pulp are removed with barbed

broaches and files, in a careful and methodological manner using moderate lateral pressure

and vertical movements to avoid weakening of root canal walls, along with copious irrigation

using 0.5% NaOCl and saline. It is important that vital tissue present in apical part of pulp

lumen should not be removed as this may improve the quality and speed of apical bridging or

provide further root development.

4. Root canal is dried with large sterile paper points.

5. Ensure that there are no signs and symptoms of active infection such as tenderness on

percussion that contraindicate the sealing of the canal space.

6. Calcium hydroxide paste can be placed in the canal to disinfect for about 1 week to not

more than one month. Tooth is restored with temporary filling.

7. On next appointment, Calcium hydroxide is removed by liberal irrigation. Gently dry the

canal, being careful not to stimulate bleeding from the level at which vital tissue is present.

Total dry canal is not required as MTA requires moisture to set.

8. Mixed MTA is placed in the cavity using a large amalgam carrier. The material is pushed

towards the apical foramen with endodontic plugger smaller than root canal diameter whose

length is marked with rubber stopper.

9. The apical plug should be at least 3-4 mm thick and this should be checked with IOPAR.

Entire canal can also be filled with MTA. If the apical plug could not be placed adequately,

the entire material is rinsed from the canal with sterile water and the procedure repeated

10. A moist cotton pellet is placed in the canal and the tooth is temporarily restored until the

MTA is cured (4-6 hours)

11. After that, temporary restoration and cotton pallet is removed and the remaining canal is

obturated with gutta percha and a permanent restoration is then placed.

Recently, the use of resorbable materials such as freeze dried bone, collagen plug or other

biocompatible material packed into the apical region to serve as a matrix or barrier against

which MTA may be condensed has been suggested in cases of immature teeth where it is

very difficult to create an adequate 3- 4 mm plug in orthograde manner.

There are many reports that disclose successful treatment of teeth with necrotic pulps and

open apexes by using MTA as an apical barrier.

Current data show that MTA can be used as an apical barrier in teeth with necrotic pulps and

open apexes. More investigations are needed to prove its long term efficacy. The placement

of an MTA apical barrier was viewed as a promising alternative to traditional, multiple-visit

apexification with calcium hydroxide. The advantages were cited as

 Reduced treatment time

 Reduced risk of calcium hydroxide induced changes to dentine, and consequently

reduced fracture risk,

 Early placement of a reinforcing coronal/ intra-radicular restoration.

Limitations:
It still did little to improve on 2 shortcomings of the Ca(OH)2 apexification technique:

 Predisposition to root fracture and

 Failure to stimulate root development

To increase the fracture resistance of roots after apexification procedures

 Filling the root canal from mid root to coronal third along with restoration of acceess

cavity using resin bonded restoration is suggested.

PULP REVASCULARIZATION

Regenerative endodontic procedures are biologically based procedures designed to restore

function to a damaged and non-functioning pulp by stimulation of existing stem and

progenitor cells present in the root canal and/or the introduction and stimulation of new stem

and dental pulp progenitor cells into the root canal under conditions that are favorable to their

differentiation and reestablishment of function.

Nygard Ostby is the pioneer of regenerative endodontic procedures. He showed that new

vascularized tissue could be induced in the apical third of the root canal of endodontically

treated mature teeth with necrotic pulps and apical lesions.

Rationale behind this approach is that

 There is persistence of vital pulpal tissues in root canals of teeth having periapical

radiolucencies. This is more common in immature teeth than mature teeth (Lin et al

1984). Under favourable and sterile conditions, these cells can participate in the

regenerative process.

 The recent demonstration in several clinical case reports that despite the formation of

periapical abscesses with extensive periradicular bone resorption as the result of root
 canal infection in immature teeth, conservative treatment may allow root development

to reach their maturation.

 These observations are underscored by the discovery of some of the dental stem cells,

which may, under appropriate sterile environment, induce healing within the root

canal space and the continued maturation of roots after endodontic treatment of the

immature permanent teeth.

For example, the observation of severely infected pulp in immature teeth capable of

undergoing complete root maturation after proper disinfection procedures may be

explained by the possibility that SCAP somehow survive from infection.

STEM CELLS FOR PULP REGENERATION: -

Stem cells are defined by having two major properties: (1) they are capable of self-renewal

and (2) when they divide, some daughter cells give rise to cells that eventually become

differentiated cells. Basic types are :

i) totipotent stem cells: each cell is capable of developing into an entire organism

(ii) pluripotent stem cells: cells from embryos (embryonic stem cells) that when grown in the

right environment in vivo are capable of forming all types of tissues

(iii) multipotent stem cells: postnatal stem cells or commonly called adult stem cells that are

capable of giving rise to multiple lineages of cells. Dental stem cells belong to this category.

These include: (i) dental pulp stem cells (DPSCs), (ii) stem cells from exfoliated deciduous

teeth (SHED) (iii) stem cells from apical papilla (SCAP), (iv) periodontal ligament stem cells

(PDLSCs) , (v) follicle precursor cells (DFPCs). Among them, all except SHED are from

permanent teeth.
These dental stem cells possess different levels of capacities to become specific tissue

forming cells. DPSCs and SHED are from the pulp and SCAP is from the pulp precursor

tissue, apical papilla.

These dental stem cells may potentially be utilized for dental tissue regeneration, i.e.,

pulp/dentin and periodontal ligament. More importantly, the identification of these dental

stem cells provided us a better understanding of the biology of pulp and periodontal ligament

tissues and their regenerative potential after tissue damage.

Terminology confusion

Trope claimed that the term revascularization was chosen because the nature of the tissue

formed post treatment was unpredictable, and the only certainty was the presence of a blood

supply; hence it was ‘‘revascularized.’’

Huang and Lin suggested the term “induced or guided tissue generation and regeneration”.,

Lenzi and Trope suggested the term “revitalization” as being more appropriate because it is

descriptive of the nonspecific vital tissue that forms in the root canal.

Weisleder and Benitez suggested the term “maturogenesis” best describes the physiologic

development of the root that occurs rather than development restricted to the apical segment.

Hargreaves et al used the term “maturogenesis” to describe ‘‘continued root development’’

in contrast to apexogenesis, which they describe as ‘‘apical closure.’’ Huang and Lin also

have suggested the use of this term when a non traditional approach is used in the treatment

of non vital immature permanent teeth with apical pathosis.

To avoid confusion, the term “apexogenesis” is used for procedures designed to encourage

continued apical development in teeth with some vital tissue in the root canal, and the term
“maturogenesis” be used for procedures that promote continued root development in infected

immature permanent teeth, rather than revascularization or revitalization.

Guidelines for revascularization that have been recommended for the treatment of infected

immature permanent teeth, with or without apical pathosis.

Appointment #1

 An assessment of the patient should be performed, including the state of tooth

development, extent and history of the endodontic infection, and the restorability of

the crown (without the need of pulp space for post), before the procedure is

undertaken. These factors are important in ensuring that a predictable outcome can be

achieved. Immature permanent teeth with necrotic pulp, with or without apical

pathosis, and an incomplete developed root with an apical opening that measures 1

mm or larger are considered suitable candidates for treatment, providing the crown,

when damaged, is restorable.

 An informed consent must be signed by the patients’ parents/ guardians, who must be

informed that this is a relatively new procedure with no standardized guidelines.

Furthermore, they must be told that follow-up appointments are obligatory to assess

the outcome of initial treatment and to discuss other treatment options if this treatment

should fail to meet expected goals, ie, reduction or resolution of apical lesion when

present, continued root development with reduction in the size of the apical foramen,

and deposition of additional hard tissue on the root canal walls.

 The tooth should be anesthetized, a rubber dam placed, the tooth and working field

disinfected, and straight line access made to allow the necrotic tissue in the pulp

chamber to be removed after initial irrigation of the root canal. The canal should be
 inspected by using dental magnification to confirm or refute the presence of residual

vital tissue and the level to which it may be present in the root canal. This is the first

phase in determining the type of treatment that will follow (revascularization or

apexogenesis).

Suggested Revascularization Guidelines

 Debridement and Disinfection - Mechanical cleaning is contraindicated because it

may weaken the thin dentinal root walls, as well as remove vital tissue remnants that

might be present in the apical part of the canal. A K-file, or alternatively a gutta-

percha cone, should be introduced into the canal to establish a working length. In

cases when inserting a file or gutta-percha cone into the canal, a little resistance

caused by the presence of tissue is felt and/or although anesthetized, the patient

reports a sensation of pain, residual vital tissue should be suspected, and an

apexogenesis procedure should be performed.

 Removal of necrotic tissue from the root canal is accomplished by gently irrigating

the root canal with a minimum of 20 mL 2.5% NaOCl dispensed through a syringe

and a 20-gauge needle. NaOCl is a potent antimicrobial agent and effectively

dissolves necrotic and organic tissue. Although higher concentrations of NaOCl are

potentially toxic to periapical tissue, Trevino et al found that the survival rate of

human stem cells of the apical papilla (SCAP) exposed to 6% NaOCl, followed by

17% EDTA and then 6% NaOCl again, was 74%.

 When irrigating with NaOCl, the needle should be introduced into the root canal to a

point 2 mm short of the apical foramen and the NaOCl is slowly expressed from the

syringe to prevent its introduction into the periapical tissues. Restricting the needle to
 a position 2 mm short of the apex is based on the finding that when a syringe plunger

is slowly compressed, the solution only extends 1 mm beyond the tip of the needle.

 Initial NaOCl irrigation is followed by irrigation with 5 mL sterile saline to prevent a

possible interaction between NaOCl and 10 mL 2% CHX that is used as a final rinse.

CHX is recommended because of its antimicrobial activity and its substantivity, i.e,

the ability to extend antimicrobial action by interacting with the dentin. Because CHX

has no tissue dissolution capabilities, it should not be used as the only irrigation

solution.

 Root Canal Medication - After the root canal has been irrigated, it should be carefully

dried with large, sterile paper points. The root canal can then be medicated with 1 of 2

dressings, each leading to a possible different outcome.

a) Antibiotic Combination - An intracanal antibiotic dressing can be placed into the root canal

to a depth 2 mm short of the root apex and to allow room for reestablishment of a new

vasculature and formation of new hard tissue on the root canal walls. Hoshino et al

introduced a triple antibiotic combination of ciprofloxacin, metronidazole, and minocycline

that they claimed was sufficiently potent to eradicate bacteria from the dentin of the infected

root and promote healing of the apical tissues. The medicament is made by mixing equal

doses of the 3 antibiotics with propylene glycol in macrogol ointment to a paste-like

consistency. Reynolds et al used a mixture of 250 mg each of ciprofloxacin, metronidazole,

and minocycline with sterile water. Before mixing, it is important to ensure that the

metronidazole and ciprofloxacin tablets are ground into a fine powder to give the paste a

cream-like consistency. Minocycline, which is available in capsule form, only needs to be

opened and added to the mixture.

The paste can be inserted into the root canal with a lentulo spiral or with a syringe-type

carrier. Once placed into the root canal, it should be tapped down the canal gently with a

moist cotton pellet to extend it to a point 1 mm short of the root apex. The use of this

antibiotic combination has been supported by Banchs and Trope. Windley et al showed a

99% reduction in mean colony-forming units (CFUs), with approximately 75% of the root

canal showing no cultivable microorganisms after the triple antibiotic mixture was applied.

This reflected a high efficacy. Sato et al investigated that the antiseptic properties of a

combination of ciprofloxacin, metronidazole, and cefaclor was equally effective. Thibodeau

and Trope reported substituting cefaclor for minocycline in the Hoshino triple antibiotic

formula to avoid dentin discoloration, a problem that often accompanies the intracoronal use

of minocycline. Reynolds et al have suggested that the discoloring effect of the minocycline

can be minimized by coating the dentinal tubules in the pulp chamber with a bonding agent,

then placing a root canal projector (CJM Engineering Inc, Santa Barbara, CA) into the

chamber, and filling the space between the projector and the dentin with a flowable

composite resin. After the resin sets, the projector can be removed, and the triple antibiotics

paste can be placed into the canal in a backfill manner to the level of the CEJ. Cefaclor

instead of minocycline can also be substituted in the paste to avoid discoloration.

Concerns other than tooth discoloration - First, there is the fear of promoting antibiotic

resistance in some root canal bacteria. Recent reports have shown that this is already

developing in bacteria recovered from endodontic infections. Second, there is a risk of

precipitating an allergic reaction in a sensitive patient or inducing sensitivity in a patient who

has never been sensitive. These concerns highlight the need for a full and comprehensive

medical and dental history of the patient before treatment, regardless of the method of

administering the antibiotic during the course of treatment. Finally, because the preservation

of residual cells is critical to a favorable outcome of the treatment, it is important that any
antimicrobial medicament including antibiotics or antibiotic combinations be biocompatible.

Gomes-Filho et al evaluated the effect of triple antibiotics on rat subcutaneous tissue at

different time periods and concluded that it is biocompatible. On the other hand, Wang et al

believed that highly concentrated antibiotic paste might be toxic to live tissue. Discrepancies

such as these highlight the need to undertake additional clinical research to better understand

the biological effects of the drug concentration used and their optimal period of application.

b) Calcium Hydroxide Ca(OH)2 has been advocated as a root canal disinfectant and for

stimulation of hard tissue repair (apexification) at the apex of infected immature teeth. Its

method of use has now been modified to comply with the demands of treatment designed to

stimulate new hard tissue deposition on the root canal walls and continued growth of the root.

Its use is advisable when sensitivity to one of the antibiotics used in Hoshino or modified

Hoshino paste has been reported. Cehreli et al demonstrated that regenerative endodontic

treatment of multirooted immature necrotic teeth by using Ca(OH)2 in the coronal third of the

root canal was a viable alternative to conventional apexification treatment. All teeth in their

study demonstrated absence of clinical symptoms, radiographic evidence of periapical

healing, progressive thickening of dentinal walls, and continued apical development.

 The maturation procedure requires preservation of vital tissue and a stimulation of

odontoblast-like and HERS cells. The use of Ca(OH)2 in revascularization is therefore

not without criticism. Some authors claim that because of its high pH, it can destroy

cells vital to the repair process. Others fear it may induce an uncontrolled calcification

of the canal space that would prevent the ingrowth of soft tissue with an odontogenic

potential. In contrast, clinicians who advocate its use believe that by restricting its

placement to the coronal third of the root canal, its beneficial properties can be used

and its toxicity limited.

  Ca(OH)2 should not be placed into the root canal with a lentulo spiral. Instead, it

should be placed to the coronal portion of the root canal with a syringe-type carrier

and then tamped down gently with a moist cotton pellet to the junction of the coronal

and middle thirds of the root length. This can be confirmed by x-ray.

 Temporary Restoration. Preventing coronal leakage of bacteria into the cleaned and

medicated root canal is a primary prerequisite for successful revascularization. It is

for this reason that a double coronal restoration is recommended. This is done by

placing a sterile cotton pellet over the root canal medicament and then covering the

pellet with Cavit cement. The Cavit is, in turn, covered with glass ionomer cement

that affords the seal greater resistance to wear and the occlusal forces during the long

interval that can occur between appointments. It is advisable to use non-eugenol

temporary cements. Eugenol containing cements, such as intermediate restorative

material, can contaminate the preparation, thus inhibiting the polymerization of

certain resin composites subsequently used as permanent restorative filling material.

 Medication Period. No agreement exists concerning the preferred medication or the

optimal period for leaving medication in the root canal. Different clinicians have used

different periods that have ranged from 7 days to several weeks.

Appointment #2

Before proceeding with the next phase of treatment, it is important to ensure that all clinical

signs and symptoms have abated. If clinical signs or symptoms persist, the procedures

performed in the first appointment should be repeated. If they continue to persist over several

appointments, an apexification procedure should be considered.

  The tooth should be anesthetized before the rubber dam is placed. An anesthetic

without vasoconstrictor should be chosen to prevent constriction of the blood vessels

in the apical region or a limited flow of blood when bleeding is mechanically induced.

After careful removal of the temporary restoration the medicament should be removed

by gently irrigating the root canal by using a minimum of 20 mL 2.5% NaOCl. The

irrigation should be repeated until no medicament is evident in the canal. From that

point on, the irrigation protocol is similar to that used during the first appointment

with one exception, the substitution of 10 mL 17% EDTA instead of CHX as a final

rinsing solution. Use of EDTA at this time is as a chelating agent; it can decalcify the

surface of the root canal dentin and expose its collagen fibers. Collagen possesses

adhesion motifs for the adhesion of new cells, whereas the decalcification of the

dentin releases bound growth factors that can attract new cells and promote their

differentiation into cells with odontoblast-like properties. Both are potentially

valuable assets in the regenerative procedure. The use of EDTA as a final rinse was

promoted by Yamauchi et al, who concluded after their animal study that EDTA had

no negative effect and helped in the formation of a calcified tissue that led to

strengthening of the root walls. This protocol was also proposed by Trevino et al,

who showed that irrigation with 17% EDTA or a combination of 17% EDTA and 6%

NaOCl was compatible with stem cell survival, whereas irrigation protocols that

included 2% CHX were not. It was feared that because of its substantivity, CHX

could interfere with the binding of SCAP cells to the extracellular dentinal matrix.

 Scaffold :

Pulp stem cells must be organized into a three-dimensional structure that can support cell

organization and vascularization. A scaffold should contain growth factors to aid stem cell

proliferation and differentiation, leading to improved and faster tissue development. The
scaffold may also contain nutrients promoting cell survival and growth and possibly

antibiotics to prevent any bacterial in-growth in the canal systems. In addition, the scaffold

may exert essential mechanical and biological functions needed by replacement tissue.

 To achieve the goal of pulp tissue reconstruction, scaffolds must meet some specific

requirements. Biodegradability is essential, since scaffolds need to be absorbed by the

surrounding tissues without the necessity of surgical removal. The rate at which

degradation occurs has to coincide as much as possible with the rate of tissue

formation; this means that while cells are fabricating their own natural matrix

structure around themselves, the scaffold is able to provide structural integrity within

the body, and it will eventually break down, leaving the newly formed tissue that will

take over the mechanical load. A high porosity and an adequate pore size are

necessary to facilitate cell seeding and diffusion throughout the whole structure of

both cells and nutrients.

 The types of scaffold materials available are natural or synthetic, biodegradable or

permanent. The synthetic materials include polylactic acid (PLA), polyglycolic acid

(PGA), and polycaprolactone (PCL), which are all common polyester materials that

degrade within the human body. Scaffolds may also be constructed from natural

materials; Several proteic materials, such as collagen or fibrin, and polysaccharidic

materials, like chitosan or glycosaminoglycans (GAGs), have not been well studied.

 In replanted avulsed and extracted teeth, the retained avascular pulp is used as the

scaffold for the ingrowth of new pulp tissue. Its role has led to a clinically acceptable

level of success in retaining these teeth and promoting continued root development.

Few examples of scaffold materials being used in revascularisation are:

1) BLOOD CLOT: - A protocol for using a stable blood clot that can act as a scaffold in the

revascularization of infected immature teeth has been suggested by numerous researchers.

The assumption is that by inducing bleeding into the disinfected canal, a stable blood clot can

be established that will not only serve as a scaffold but also provide factors that stimulate

their cell growth and differentiation of these cells into odontoblast-like cells.

 The suggested protocol begins with the introduction of a sterile #20 K-file into the

apical tissues 2 mm past the apical foramen to initiate bleeding into the root canal.

Bleeding should be controlled so that it does not extend beyond a point approximately

3 mm apical to the CEJ. This is done by applying intracanal pressure with a sterile

saline soaked cotton pellet until a clot is formed. Estimated mean time for the

establishment of a stable blood clot is 15 minutes. The clot can be carefully touched

with the reverse end of a large sterile paper point to confirm its stability. Once

stability is confirmed, the clot should be carefully covered with MTA cement that is

back-filled to the level of the CEJ. It is important to note that revascularization and

the generation of new tissue will not occur in this area, which predisposes the tooth to

fracture in this area. However, to date, there have been no clinical reports of this

happening. It also should be noted that when the blood clot is not stable, it can break

down and allow the MTA to be pushed farther down the root canal. Although not

necessarily detrimental to a favourable outcome, its apical displacement can interfere

with the depth of new tissue that grows into the root canal. After its initial set, a wet

cotton pellet should be placed over the MTA and the access opening sealed with a

temporary restoration.

It is important to note that there are now several types of tri-mineral cements available for use

in revascularization and that they have different setting and biocompatibility characteristics.

Nosrat et al reported 2 successful cases of revascularization in necrotic immature molars by

using calcium-enriched mixture cement. Biodentine has also been claimed to be used in place

of MTA. However, recommendations for the use of mineral cement in this protocol are

limited to MTA because of the large number of studies that have been published over the

years in support of its use in cases such as these.

2) PLATELET RICH PLASMA AND PLATELET RICH FIBRIN: Torabinejad M and

Turman M reported revitalization of tooth with necrotic pulp and open apex by using

platelet-rich plasma. They conclude PRP potentially an ideal scaffold for this procedure.

Keswani D and Pandey R recently reported continued thickening of root canal walls, root

lengthening and apical closure in a non vital maxillary right central incisor, in which they

used PRF in canal after disinfection (without induction of bleeding), at 15 months

radiographic examination follow up. They conclude that Platelet-rich fibrin might serve as a

potentially ideal scaffold in revascularization of immature permanent teeth with necrotic

pulps as it is rich in growth factors, enhances cellular proliferation and differentiation,

augments angiogenesis, acts as a matrix for tissue in growth, regulates inflammatory

reactions and has anti-infective properties. Additionally, it acts as an excellent matrix to

support MTA placement. The disadvantages are invasiveness of procedure, additional

equipment, difficulty in handling and placing PRF in canal space and increased cost of

treatment.

3) COLLAGEN (WITH AND WITHOUT AN INDUCED BLOOD CLOT): In a study by

Yamauchi et al, a histomorphometric analysis of canines treated with a revascularization

protocol showed significantly more mineralized tissue formation in the root canal when a

blood clot was used in combination with a cross-linked collagen scaffold. In another case

series by Jung et al, the procedure failed in one of the teeth when bleeding into the root canal

could not be induced. When a clot was formed in combination with Collatape (Sulzer Dental
Inc, Plainsboro, NJ), however, there was complete resolution of the apical radiolucencies and

continued apical closure after 17 months. Several studies have suggested that the use of a

polymer scaffold is the most promising means of inducing replacement tissues through tissue

engineering.

4) PULP IMPLANTS: Gotlieb et al investigated the ultrastructural appearance of tissue-

engineered pulp constructs implanted within cleaned and shaped teeth. Their results support

the concept that it is possible to implant tissue-engineered pulp constructs such as stem cells

from human exfoliated deciduous teeth into endodontically treated teeth. Future regenerative

endodontic treatment could very well involve the use of similar laboratory-created constructs

for regenerative procedures. Although pulp constructs hold great promise, they should be

considered experimental and as yet unproven for clinical use.

Appointment #3

The third appointment is principally scheduled to remove the cotton pellet, confirm the set of

the MTA, and place a permanent restoration into the access opening. It is possible to avoid a

third appointment by waiting for the MTA to set during the second appointment.

Suggested Apexogenesis Guidelines: Treatment in Cases of Confirmed Residual Vital Tissue

Perform an apexogenesis procedure if vital pulp remnants have been confirmed. The root

canal should be disinfected with copious amounts of NaOCl flowed into the root canal by a

syringe carried to a depth 1 mm short of the level of the vital tissue. The root canal should

then be gently filled with a mixture of antibiotics or Ca(OH)2 to the vital tissue, and the

access opening should be temporarily sealed. The medication should remain in the root canal

for up to 1 month.
At the second appointment, it is important to ensure that there has been resolution of signs

and symptoms. If clinical signs and/or symptoms persist, the first appointment guidelines

should be repeated. If the clinical symptoms still persist after treatment repetition, other

procedures should be considered. If no signs and symptoms are present, the medication

should be irrigated out, the root canal dried, and MTA carefully placed over the vital tissue in

the root canal below the level of the CEJ. A moist sterile cotton pellet is placed over the

MTA, and the access is sealed with a temporary restoration. The next appointment is

principally scheduled to remove the cotton pellet, confirm the set of the MTA, and restore the

access opening with a permanent restoration. It is possible to avoid this appointment by

waiting until the MTA has set during the second appointment.

Follow-up and Treatment Outcome

No standard follow-up protocol exists for revascularization procedures. Different clinicians

have advised different follow-up periods in their case reports, with some lasting as long as 5

years post treatment. In the majority of the cases, improvement or resolution of the apical

lesion can be expected in approximately 6 months and root elongation and apical closure,

with thickening of the root canal walls, within 12–24 months postoperatively. Most clinicians

suggest that during the first year, 3-month recalls should be scheduled followed by 6-month

recalls unless clinical symptoms develop. Five types of responses of immature permanent

teeth with infected necrotic pulp tissue and either apical periodontitis or abscess to

revascularization procedures were observed (Chen et al 2008)

Type 1, there was increased thickening of the canal walls and continued root maturation

Type 2, there was no significant continuation of root development and the root apex became

blunt and closed

Type 3, there was continued root development and the apical foramen remained open

Type 4, there was severe calcification (obliteration) of the canal space

Type 5, there was a hard tissue barrier formed in the canal space between the coronal MTA

plug and the root apex

Disadvantages of revascularization technique:

a) Discolouration- mainly due to minocycline in triantibiotic paste, also caused by MTA plug

whether grey or white.

b) Prolonged treatment period - mainly due to disinfection period which vary between one to

several weeks.

c) Poor root development might occur in some case

d) Root canal calcification and obliteration is also a possible outcome.

Conclusion

There is no universal protocol described in the literature, but most depend on the same

principles:

(1) Chemical disinfection of the canal without instrumentation,

(2) Production of a suitable environment for a scaffold to support tissue in growth; and

(3) A tight bacterial seal of the access opening to prevent the ingress of bacteria.

Like all dental procedures, careful case selection and full disclosure to the patient (and

parent) regarding the goals and limitations of the treatment are essential to make this form of

mainstream treatment as an acceptable alternative in the clinical management of infected

immature teeth. Long-term studies are warranted to assess subsequent outcomes such as the
redevelopment of apical periodontitis and the incidence of pulp canal obliteration. Unless

accompanied by signs and/or symptoms of infection, it is advisable that no further treatment

beyond maturation be undertaken because most of these cases will remain functional and

disease free for many years.