Regenerative Endodontics
Treatment Outcomes of Apexification or
Revascularization in Nonvital Immature
Permanent Teeth: A Retrospective Study
Jidapa Silujjai, MDSc, and Pairoj Linsuwanont, PhD
Abstract
Introduction: The purposes of this retrospective study
were to evaluate the clinical and radiographic outcomes
of mineral trioxide aggregate apexification and revascu-
larization in nonvital immature permanent teeth and to
analyze factors influencing treatment outcome.
Methods: Forty-six cases (29 cases of apexification
and 17 cases of revascularization) were recruited into
this study. Patients’ preoperative and postoperative in-
formation was analyzed. Treatment outcomes were
categorized as a success or failure and functional reten-
tion. Further root development was assessed in terms of
the percentage changes in root length and root width.
Results: The success rates of mineral trioxide aggregate
apexification and revascularization were 80.77% and
76.47% and functional retention was 82.76% and
88.24%, respectively. Revascularization provided signif-
icantly greater percentage changes in root width
(13.75%) in comparison with mineral trioxide aggregate
(MTA) apexification ( 3.30%). The mean percentage
change of increased root length was 9.51% in the revas-
cularization group and 8.55% in the MTA apexification
group. Interestingly, revascularization showed various
degrees of increased root length ranging from 4% to
58%. Fracture was the main cause of failure in MTA
apexified teeth. All failed revascularized teeth presented
with signs and symptoms of apical periodontitis caused
by persistent infection. Conclusions: MTA apexification
and revascularization provide a reliable outcome in the
aspects of resolution of the disease and tooth functional
retention. None of these treatments provides satisfac-
tory predictable further root development. (J Endod
2017;43:238–245)
Key Words
Apexification, clinical outcome, immature teeth, mineral
trioxide aggregate, regenerative endodontics, revascu-
larization
From the Faculty of Dentistry, Department of Restorative Dentistry, Chulalongkorn University, Bangkok, Thailand.
Address requests for reprints to Pairoj Linsuwanont, Faculty of Dentistry, Department of Restorative Dentistry, 34 Henri-Dunant Road, Patumwan, Bangkok,
Thailand 10330. E-mail address: linspairoj@gmail.com
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.10.030
238 Silujjai and Linsuwanont
T he development of
immature teeth can be
arrested because of
Significance
MTA apexification and revascularization provide
reliable outcomes in the aspects of resolution of
various harmful stimuli
the disease and tooth functional retention. None
such as trauma, caries,
of these treatments provides satisfactory predict-
and anatomic variations
able further root development.
such as dens evaginatus
(1). As a result of pulp ne-
crosis, nonvital immature teeth remain with fragile dentinal walls, which are susceptible
to fracture resulting in tooth extraction (2). The aims of treatment of nonvital immature
teeth should be the resolution of disease; tooth retention; and, if possible, the promo-
tion of continued root development.
Apexification and revascularization have been considered effective treatment pro-
cedures for nonvital immature teeth. Apexification involves disinfection of the root ca-
nal, promoting an apical hard tissue barrier and obturating the empty canal space with
root filling material. On the other hand, revascularization aims to promote continued
root development, the replacement of lost tissue, and function with stem cell–mediated
growth of reparative tissue (3).
Several studies (4, 5) have compared the effectiveness between apexification and
revascularization in terms of success and further root development. The evaluation of
treated teeth was based on clinical and radiographic examination. Both procedures
provided satisfactory successful outcomes, with success rates ranging from
76%–100% (4–21). In terms of continued root development, researchers attempted
to quantify the changes of root length and root dentin thickness from conventional
radiographs (4, 5, 16, 20–22). The existing literature showed various changes of
percentage changes in continued root development, with root length ranging
from 2.7 to 25.3 and root width from 1.9 to 72.6 (4, 5, 16, 21).
The quantitative measurement of dimensional changes of preoperative and post-
operative conventional radiographs is challenging. The problems are the difference in
angulation between preoperative and postoperative images and the calibration of mea-
surement changes into a millimeter scale. Several studies (4, 5, 16, 20–23) used a
geometric imaging program to adjust the images to reduce differences in angulation
between preoperative and recall images as suggested by Bose et al (24). Recently, Kah-
ler et al (21) found that Bose et al’s technique can control changes in angulation but
may introduce other measurement errors. Flake et al (23) suggested that it is better to
measure the radiographic root area rather than root length and root width. However, to
date, the accuracy of these measurement techniques has not been verified.
The purposes of this study were to evaluate the clinical and radiographic outcomes
of mineral trioxide aggregate (MTA) apexification and revascularization in nonvital
JOE — Volume 43, Number 2, February 2017

immature permanent teeth in terms of success and continued root
development with a modified measurement method and to analyze fac-
tors influencing treatment outcome.
Materials and Methods
Recruitment of Patients
The study protocol was approved by the ethics committee of the
Faculty of Dentistry, Chulalongkorn University (ref 18/2016), Bangkok,
Thailand. Patients’ dental records from 2008 to 2014 at the postgrad-
uate endodontic clinic were searched for cases with nonvital immature
permanent teeth that were treated by either MTA apexification or revas-
cularization. Cases with at least a 1-year follow-up with adequate preop-
erative, intraoperative, and postoperative data including radiographs
were selected.
Treatment Protocol
All treatment was performed by postgraduate students. All cases
were performed under a dental microscope (Zeiss, Oberkochen, Ger-
many) with rubber dam application. In revascularization cases, the first
visit consisted of local anesthesia; access cavity preparation; working
length determination; irrigation with 1.5%–2.5% sodium hypochlorite
and 17% EDTA; intracanal medication with either calcium hydroxide or
a mixture of ciprofloxacin 250 mg, metronidazole 400 mg, and mino-
cycline 50 mg in the proportion of 1:1:1 (25); and temporary restora-
tion. At the second visit, blood clot formation was induced into the canal
system followed by MTA application with a thickness of approximately
2–3 mm and a coronal seal with bonded restoration. For MTA apexifi-
cation treatment, 2.5% sodium hypochlorite was used for irrigation and
calcium hydroxide was used as intracanal medication between visits.
MTA was put into the root canal, and a moistened cotton pellet was
placed over the MTA. At the following visit, the root canal was obturated
with injectable gutta-percha (Obtura II; Obtura Spartan, Fenton, MO)
and AH Plus sealer (Dentsply DeTrey, Konstanz, Germany). Teeth
were referred to operative specialists for permanent restoration.
Patients were scheduled for post-treatment follow-up examina-
tions at 6 months, 12 months, 2 years, 3 years, 4 years, and 5 years.
Data of the clinical examination and radiographic examination were re-
corded in the patients’ treatment records.
Data Collection
Data were collected from the patients’ records. Preoperative data
included tooth number, sex, age, etiologies of pulp necrosis, pulpal
diagnosis, periapical diagnosis, the absence or presence (including
size) of a periapical radiolucency lesion, and Cvek’s stage of root devel-
opment (2). Intraoperative data included the date of treatment comple-
tion and the type of permanent restoration.
The follow-up clinical examination data included the presence or
absence of clinical symptoms, sensitivity to percussion, palpation, sinus
tract, type and quality of restoration, pathological probing depth, tooth
mobility, crack or fracture, and traumatic occlusion. The preoperative
and follow-up radiographs were taken using the standardized paralle-
ling technique with the use of the Rinn XCP alignment system (Rinn Cor-
poration, Elgin, IL). The follow-up radiographs were taken with an
attempt to reproduce the same angulation as the preoperative radio-
graphs. Radiographs were scanned with the Epson Photo Scanner (Ep-
son Perfection 4490 Photo Scanner; Epson Thailand Co Ltd, Bangkok,
Thailand), saved in JPEG format, and transferred to ImageJ software
(version 1.48; National Institutes of Health, Bethesda, MD) for mea-
surement and analysis of changes of root length and root width. The
evaluation of radiographic images was conducted twice with an interval
of 1 week by 2 examiners.
JOE — Volume 43, Number 2, February 2017
Regenerative Endodontics
The radiographic evaluation included the presence or absence of a
radiolucency lesion, a decrease or increase of the radiolucency lesion,
changes of Cvek’s stage of root development, and the measurement of
further root development in terms of root length and dentin thickness.
In our pilot study, we found several problems associated with Bose
et al’s measurement technique (24) (Fig. 1A and B). Moreover, the
different distance between the x-ray tube and film caused the different
magnification on the radiograph as shown in Figure 1C. If the preoper-
ative and follow-up radiographs have a different magnification, we can
calibrate using the method described in Figure 2.
Root length and dentin thickness were measured on the preoper-
ative and follow-up radiographs using the straight-line tool in the Im-
ageJ software program. Root length was measured as a straight line
from the cementoenamel junction (CEJ) to the radiographic apex of
the tooth. Dentinal wall thickness was measured at the apical one third
of the preoperative root length measured from the CEJ. The differences
of root length and dentinal wall thickness of the preoperative and
follow-up radiographs were calculated to percentage changes.
Assessment of Success and Failure
The clinical outcome assessment (modified from Friedman and
Mor [26]) consisted of success or failure and functional retention. Suc-
cess was defined as follows: both the clinical and radiographic presenta-
tions were normal or showed reduced radiolucency combined with
normal clinical presentation. Failure was defined as radiolucency that
emerged or persisted without change, even when the clinical presentation
was normal, or patients’ clinical signs or symptoms were present, even if
the radiographic presentation was normal. Functional retention was
defined as follows: the clinical presentation was normal, whereas radio-
lucency may have been absent or present (newly emerged or persisting).
Statistical Analysis
The intraclass correlation coefficient (ICC) was conducted to
assess inter- and intraexaminer reliability for quantitative measurement.
Kaplan-Meier survival curves were used to investigate the possible dif-
ferences of success and tooth retention between treatments during the
duration of the follow-up period. Univariate differences between sur-
vival curves were assessed using the log-rank test. Cox proportional haz-
ards regression was used to identify the factor that may influence
treatment outcome. The percentage changes in root length and root
width were analyzed for normality and were found to be non-
normally distributed. The nonparametric Mann-Whitney U test was
used to identify the difference between treatments. A P value < .05
was considered significant. All data were analyzed using IBM SPSS sta-
tistics v19.0 software (IBM Corp, Armonk, NY).
Results
During 2008 to 2014, 75 nonvital immature teeth were treated with
either MTA apexification or revascularization. Forty-six patients could be
contacted, and 43 subjects agreed to attend the follow-up examinations
(patient recall rate = 57.33%). The follow-up period ranged from 12 to
96 months (mean = 44 months). The 43 cases consisted of 26 cases of
MTA apexification (follow-up period = 12–96 months, mean =
49 months) and 17 cases of revascularization (follow-up period =
12–93 months, mean = 35 months). Two patients with 3 MTA apexified
teeth were unable to attend the recall examination. Patients provided the
information that teeth were functional with no symptoms.
The age of patients ranged from 8–46 years, with a median age of
13 years (first quartile = 10 years, third quartile = 20 years). The eti-
ologies of diseased teeth were trauma (46.51%), dens evaginatus
(41.86%), and caries (11.63%). The preoperative Cvek’s stage of
Apexification or Revascularization in Immature Teeth 239
Regenerative Endodontics

Figure 1. (A) Using the TurboReg plug-in application can cause image distortion; a and b are preoperative and follow-up radiographs of tooth #11 with different
angulation. Applying image correction with the TurboReg plug-in application on b causes distortion in the output image as shown in c. (B) shows the change of the
anatomic landmark between the preoperative and follow-up radiographs; d and e are preoperative and follow-up radiographs of tooth #11. Mathematic image
correction using the TurboReg plug-in application requires 3 anatomic landmarks that are supposed to be unchanged between the preoperative and the
follow-up radiographs. In this case, only 2 unchanged landmarks (mesial and distal CEJ of tooth #11) can be chosen. The root apex of tooth #21 cannot be
used as an unchanged landmark because of further root development. (C) The different distance between the x-ray tube and film causes a different size of radio-
graphic images as shown in h; a longer distance results in a smaller image, and a shorter distance results in a bigger image. f and g are radiographic images of the
same tooth with a different distance between the x-ray tube and film.

root development of diseased teeth was mainly stage 4. The majority of
immature teeth (8/12 teeth) with stage 2 or 3 root development were
treated with revascularization. Univariate Cox regression analysis could
not detect any factor influencing the treatment outcome (Table 1).
Clinical and Radiographic Evaluation in Terms of
Success and Functional Retention
There was good agreement between the 2 examiners for radio-
graphic interpretation. The interexaminer reliability of measuring the
percentage change in root length and root width was ICC = 0.996
and 0.997, respectively; the intraexaminer reliability was ICC = 0.998
and 0.981, respectively. Both of these ICC values showed excellent
reliability.
The success rates of MTA apexification and revascularization were
80.77% and 76.47%, and the functional retention rates were 82.76%
and 88.24%, respectively. Examples of successful cases are presented
in Figure 3A–D. Statistical analysis with the log-rank test showed no sig-
nificant difference between groups regarding the success rate and the

240 Silujjai and Linsuwanont JOE — Volume 43, Number 2, February 2017
 Regenerative Endodontics

Figure 2. The preoperative and follow-up radiographs have different magnifications, which can be observed from the larger size of the tooth crown of #11 and
#21. Calibration of the follow-up image to the same magnification of the preoperative radiograph will enable us to calculate the changes of tooth dimension between
preoperative and follow-up radiographs. The mesiodistal width at the CEJ is used as the reference distance (fixed dimension). The different magnification is
9/10 = 0.9. The root length is measured as a straight line from the CEJ to the radiographic apex of the tooth. The root length measurement at the mesial and distal
aspect is average. (Left) Preoperative image: mean root length = (16 + 15)/2 = 15.5. (Right) Follow-up image: mean root length = (18 + 19)/2 = 18.5. In order
to convert the follow-up radiograph measurement to have the same magnification as the preoperative measurement, we calculate as follows: mean root length = 18.5
 0.9 = 16.65 mm. The percentage change in root length = (16.65 15.5)/15.5  100 = 7.42%.
functional retention rate (Table 2). The Kaplan-Meier plot (Fig. 4) fracture. All failed revascularized teeth presented with signs and symp-
showed the probability of success of each treatment at the different pe- toms of apical periodontitis caused by persistent infection.
riods of follow-up. The plot showed that failed revascularized teeth
could be detected within 3 years after treatment.
The failed cases are analyzed and presented in Table 3. Failed MTA Radiographic Evaluation of Further Root Development
apexified teeth (5 teeth) consisted of 2 teeth with vertical root fracture, 1 Revascularization produced a significantly increased root width
tooth with horizontal root fracture, and 2 teeth with unrestorable crown (mean = 13.75%) in comparison with MTA apexification ( 3.30%).
TABLE 1. Success Rate Distributions according to Preoperative and Postoperative Factors
MTA apexification, Revascularization, Success,
Variable n (%) n (%) Total (n = 43) n (%) P value
Sex .622
Male 12 (46.15) 7 (41.18) 19 (44.19) 16 (84.21)
Female 14 (53.85) 10 (58.82) 24 (55.81) 18 (75)
Age .686
#15 y 17 (65.38) 14 (82.4) 31 (72.09) 25 (80.65)
>15 y 9 (34.62) 3 (17.6) 12 (27.91) 9 (75)
Etiology .292
Trauma 15 (57.69) 5 (29.41) 20 (46.51) 17 (85)
Dens evaginatus 8 (30.77) 10 (58.82) 18 (41.86) 13 (72.22)
Caries 3 (11.54) 2 (11.76) 5 (11.63) 4 (80)
Cvek’s stage of root development .594
Stage 2,3 4 (15.38) 8 (47.06) 12 (27.91) 10 (83.33)
Stage 4 22 (84.62) 9 (52.94) 31 (72.09) 24 (77.42)
Periapical status .908
Asymptomatic apical 15 (57.69) 5 (29.41) 20 (46.51) 16 (80)
periodontitis
Symptomatic apical periodontitis 2 (7.69) 1 (5.88) 3 (6.98) 3 (100)
Acute apical abscess 2 (7.69) 1 (5.88) 3 (6.98) 3 (100)
Chronic apical abcess 7 (26.92) 10 (58.82) 17 (39.53) 12 (70.59)
Restoration .453
Filling 23 (88.46) 16 (94.12) 39 (90.70) 31 (79.49)
Crown 3 (11.54) 1 (5.88) 4 (9.30) 3 (75)
MTA, mineral trioxide aggregate.

JOE — Volume 43, Number 2, February 2017 Apexification or Revascularization in Immature Teeth 241
Regenerative Endodontics

Figure 3. Radiograph representatives of successful cases illustrate the resolution of the radiographic periapical lesion and root maturation. (A and B) A successful
revascularization case with a 32-month follow-up. (C and D) A successful MTA apexification case with a 68-month follow-up. The arrows indicate further root
development and the resolution of periapical radiolucencies.

In terms of increased root length, there was no statistically significant
difference between groups (Table 2). The measured percentage
changes of root length were 9.51% (revascularization) and 8.55%
(MTA apexification).
Revascularized teeth with stage 2 or 3 root development showed
various increases in root length ranging from 4% to 58%
(Table 4). Two revascularized teeth in this group exhibited profound
root maturation, changing from stage 2 or 3 to stage 5 and increased
root length of 44% and 57% (Table 4). However, statistical analysis
did not show a significant difference among treatment groups with a
similar stage of root development.
Discussion
The interpretation of conventional radiographs is influenced by
the quality of the images and the angulation of the radiographs. In
our pilot study, adjusting angulation with the TurboReg algorithm as
suggested by Bose et al (24) occasionally led to image distortion or
elongation. This technique required the examiners to choose 3
anatomic landmarks that were supposed to be unchanged, such as
CEJ and apices of adjacent teeth, between the preoperative and
follow-up radiographs. Because most cases were young children with
erupting dentition, applying this technique seemed to not be suitable.
Bose et al (24) calibrated the size of images by measuring images
in pixels and converting them into millimeters. The technique involved
measuring the known horizontal and vertical dimension of the film
(31 mm and 41 mm) using the ImageJ program. The reading from Im-
ageJ was shown as pixels, and the program converts the measured dis-
tance in pixels into millimeters. Different distances between the x-ray
tube and film cause different sizes of images on the radiograph. If the
preoperative and follow-up radiographs are not at the same distance
(film and x-ray tube), it will show either a bigger or smaller size of
the investigated tooth on the film. This will lead to incorrect dimension
reading. The error from the different magnification (caused by the
different distance between the film and x-ray tube) could perhaps be
minimized by using the modified technique as described in the
Materials and Methods section.
This retrospective study evaluated treatment outcome based on
clinical and radiographic evaluation. MTA apexification and revascular-
ization showed satisfactory outcomes in terms of resolution of the

TABLE 2. Treatment Outcome and Follow-up Period

Variable MTA apexification Revascularization Total
Success 21/26 (80.77%) 13/17 (76.47%) 34/43 (79.07%)
Failure 5/26 (19.23%) 4/17 (23.53%) 9/43 (20.93%)
Functional retention 24/29 (82.76%) 15/17 (88.24%) 39/46 (84.78%)
% change of root length (mean  SD) 8.55%  8.97% 9.51%  18.14% 9.05%  14.21%
% change of root width (mean  SD)* 3.30%  14.14% 13.75%  19.91% 4.11%  18.60%
Follow-up (mean  SD) 49  31.09 months 35  21.76 months 44  24.55 months
MTA, mineral trioxide aggregate; SD, standard deviation.
*There was statistically significant difference between groups.

242 Silujjai and Linsuwanont JOE — Volume 43, Number 2, February 2017
 Regenerative Endodontics

Horizontal root fracture

Vertical root fracture

Vertical root fracture

Persistent infection

Persistent infection
Persistent infection
Unrestorable tooth

Unrestorable tooth
Cause of failure

Reinfection
fracture

fracture
Follow-up

(months)
period
print & web 4C=FPO

96

28

75

76

47

20
25

37
35
Fuji II LC (GC America,
Alsip, IL) (leakage)
Temporary crown
Composite filling

Composite filling

Composite filling

Composite filling

Composite filling

Composite filling
Composite filling
Restoration

(leakage)
Figure 4. The Kaplan-Meier plot shows probability of success of each
treatment.

patients’ clinical signs and symptoms and periapical radiolucency le-

sions. The successful outcome of MTA apexification was 80.77% and

Dens evaginatus

Dens evaginatus

Dens evaginatus

Dens evaginatus
Dens evaginatus
pulp necrosis
76.47% for revascularization. Since 2007, many clinical studies have

Etiology of

Trauma

trauma

trauma
reported a consistently favorable outcome of MTA apexification

Caries
and revascularization ranging from 76.5%–100% (4–13) and
Preoperative characteristics

78%–100% (4, 5, 14–21), respectively. Another aspect to fulfilling

patients’ expectations is the functional retention of the treated teeth.
With a follow-up period up to 96 months, this study showed no statis-
tically significant difference of the functional retention rate between

Chronic apical abscess

Chronic apical abscess

Chronic apical abscess

Chronic apical abscess

Chronic apical abscess
Asymptomatic apical

Asymptomatic apical

Asymptomatic apical

Asymptomatic apical
MTA apexification (82.76%) and revascularization (88.24%).
Periapical status

periodontitis

periodontitis

periodontitis

periodontitis
Similarly, Alobaid et al (4) and Jeeruphan et al (5) found that MTA
apexification and revascularization could effectively treat nonvital
immature permanent teeth with signs and symptoms of apical periodon-
titis resulting in prolonged functional tooth retention.
Ideally, comparison of treatment outcomes between 2 treatment
procedures should be conducted in a ‘‘randomized controlled trial
study’’ in which the bias of case selection can be minimized. In this
Tooth treatment preoperative follow- up

retrospective study, the results should be interpreted with caution.

Cvek’s stage of root

There may be bias in case selection between apexification and revascu-

At

—
—
4

4
3
development

larization and the interpretation of the results from a small group of pa-
tients (26 cases of apexification and 17 cases of revascularization).
Table 1 shows only that the statistical analysis could not detect any factor
influencing treatment outcomes. More studies with large sample sizes
At

are needed to investigate factors influencing treatment outcomes.

4

4
3

4
3

Ultimately, 1 of the desired treatment outcomes should be the pro-

motion of root maturation. The literature showed various degrees of
further root development after treatment. The mean percentage changes
Age at

of root width ranged from 0%–1.4% (MTA apexification) (4, 5) and

46

12

27

34

11
10

13
13
9

10.2%–28.2% (revascularization) (4, 5, 16, 20–22). The mean

TABLE 3. A Summary of Failure Cases

percentage changes of root length were 6.1%–7% for MTA

apexification (4, 5) and 5%–14.9% for revascularization (4, 5, 16,
11

35

47

11

45

21
35

45
35

20–22). This study showed comparable results with other clinical

studies with the mean percentage changes of root width of MTA
MTA apexification

apexified teeth and revascularized teeth of 3.30% and 13.75% and

Revascularization

the mean percentage changes of root length of MTA apexified teeth

Treatment

and revascularized teeth of 8.55% and 9.51%.

Most clinical studies have reported various degrees of radio-
graphic further root development (4, 5, 21). Similar to our findings,
the extent of increased root length varied from 0%–58%. Two young
children (10 and 13 years old) with dens evaginatus gained

JOE — Volume 43, Number 2, February 2017 Apexification or Revascularization in Immature Teeth 243
Regenerative Endodontics
TABLE 4. Summary of Treated Teeth with Revascularization
Cvek’s stage of root
development % Change
Follow-up Dentin
Case Tooth Age Etiology period Preoperative Follow-up Root length thickness Outcome
1 35 23 Dens evaginatus 25 3 3 2.97 10.69 Success
2 45 10 Dens evaginatus 41 2 5 57.69 Calcified Success
3 35 13 Dens evaginatus 93 3 5 44.05 66.77 Success
4 46 46 Caries 27 4 5 2.81 0.42 Success
5 21 15 Trauma 43 3 3 0.12 2.97 Success
6 25 25 Dens evaginatus 45 3 3 4.65 14.16 Success
7 35 13 Dens evaginatus 65 4 5 3.16 Calcified Success
8 11 10 Trauma 33 4 4 0.06 4.85 Success
9 21 11 Trauma 20 4 4 6.26 19.08 Failure
10 35 10 Dens evaginatus 25 3 3 4.87 4.30 Failure
11 21 14 Trauma 12 4 4 4.36 1.31 Success
12 45 9 Dens evaginatus 13 4 4 9.20 16.43 Success
13 46 8 Caries 61 4 5 7.82 Calcified Success
14 24 11 Dens evaginatus 12 4 4 0.12 Calcified Success
15 21 12 Trauma 15 3 3 — — Success
16 45 13 Dens evaginatus 37 4 — — — Failure
17 35 13 Dens evaginatus 35 3 — — — Failure

profound increased root length of 44% and 58% after revascularization.
Three other children of a similar age with dens evaginatus showed little
increased root length (0%–4%) (Table 4). At this stage, the under-
standing of the mechanism of the continuation of further root develop-
ment after revascularization is unclear.
The importance of observed increased root length and root width
as reported by many studies should be interpreted with care. The ques-
tion is whether further root development in the range of the reported
data could strengthen the root. To date, the correlation between the
amounts of increased root length, increased root width, and physical
strength of the root (possibly in terms of fracture resistance) has never
been established. The contents of the root canal may influence the
strength of the root. The strength of 2 different root canal contents be-
tween root filling materials in MTA apexified teeth and biological tissues
including cementumlike tissue, bonelike tissue, and periodontal tissue
in the revascularized teeth has never been compared. In this study, 3
failed MTA apexified teeth were diagnosed as root fracture, which
was not found in revascularized teeth. Similar to Jeeruphan et al (5),
5 cases with apexification were extracted because of root fracture.
This incidence may be partly explained by the observations from the
in vitro studies showing that filling the root canal with gutta-percha
does not provide additional strength to the immature root after MTA
apexification (27, 28). However, whether further root development
and the development of biological tissues in the root canal after
revascularization can increase the strength of the root awaits further
investigation.
There are inconsistent results regarding the comparison of the ef-
ficiency of MTA apexification and revascularization on further root
development. Jeeruplan et al (5) reported that revascularization pro-
vided a better outcome than apexification in the aspect of increased
root length and root width. In contrast, Alobaid et al (4) could not
detect any difference between the 2 procedures. This study showed
that revascularized teeth exhibited greater increased root dentin thick-
ness than MTA apexified teeth, but we could not detect any significant
difference between these 2 procedures in terms of increased root
length. Because of the differences in reported results, we could not
conclude which procedure provided the better outcome in terms of
further root development.
Lately, the revascularization protocol has been questioned
regarding its disinfection efficiency. Several case reports showed failed
cases with signs and symptoms of apical periodontitis caused by persis-
tent root canal infection after revascularization (29, 30). Histologic
examination of extracted failed revascularized teeth with intact
coronal restoration exhibited a large area filled with necrotic debris
and thick bacterial biofilm (29). Similarly, we found that 4 failed revas-
cularization cases were diagnosed as chronic apical abscesses. These
failed cases were irrigated with 2.5% sodium hypochlorite and 17%
EDTA and intracanal medication with calcium hydroxide. The sinus
tract opening was detected in all cases. This highlights the unsatisfactory
state of the disinfection protocol. However, the treatment protocol has
been constantly revised in accordance with evidence from the most
current studies. In 2016, the American Association of Endodontists rec-
ommended using either calcium hydroxide or a low concentration
(0.1–1 mg/mL) of triple antibiotic paste as the intracanal medicament
(31). Albuquerque et al (32) recently developed triple antibiotic–
containing polymer nanofibers as a 3-dimensional tubular drug delivery
construct that provides low antibiotic concentrations and slow drug
release.
Interestingly, 2 failed revascularization cases presented with
increased root length and root width despite the presence of larger peri-
apical lesions (case 9 and 10 in Table 4). In theory, the root develop-
ment potential of immature necrotic teeth is related to the viability of the
Hertwig epithelial root sheath (HERS). The viability of HERS is influ-
enced by the severity and duration of apical infection and inflammation
(15). In these 2 failed cases, it is possible that HERS survived the
chronic apical abscess (33). The observed further root maturation in
the presence of chronic infection was also reported by Zizka et al
(30). The coexistence of heavy inflammatory infiltration and cemen-
tumlike tissue formation was shown in a histologic study in dog teeth
performed by Wang et al (34). It was suggested that inflammation
may provide factors to guide the differentiation of stem/progenitor cells
into cementoblasts.
The updated evidence illustrated that revascularization resulted in
repair rather than regeneration (3). Cementumlike tissue, bonelike tis-
sue, and connective tissue (resemblance of periodontal tissue) occu-
pied the canal space rather than dentin and pulp tissue. The ultimate
goal should be ‘‘how to make regeneration happen.’’ Along the way, re-
searchers should aim to improve the revascularization protocol in or-
der to provide reliable root canal disinfection and predictable further
root development.

244 Silujjai and Linsuwanont JOE — Volume 43, Number 2, February 2017

To sum up, there is no simple answer as to which procedure
should be the treatment of choice for nonvital immature permanent
teeth. MTA apexification and revascularization provided a satisfactory
outcome in terms of the resolution of the disease and tooth functional
retention. If the root maturation is the critical criteria for the successful
treatment, there is no treatment procedure that always fulfills that goal.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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