REGENERATIV

E
ENDODONTIC
S

GUIDED BY:
DR.P.KARUNAKAR
DR.RAJI VIOLA SOLOMON
DR.SRAVAN KUMAR
PRESENTED BY:
DR DEEPIKA
PG {3rd YEAR}
 CONTENTS part 1

INTRODUCTION
HISTORY
REGENERATIVE MEDICINE
ADULT STEMCELLS
PULP STEM CELLS
STEM CELL IDENTIFICATION
GROWTH FACTORS
SCAFFOLDS –NATURAL
ARTIFICIAL
Factors –regenerative endodontics
REFERENCES
 CONTENTS
part 2
CELL HOMING
TECHNOLOGIES OF REGENERATIVE ENDODONTICS
 ROOT CANAL REVASCULARIZATION VIA BLOOD
CLOTTING
 POST NATAL STEM CELL THERAPY
 PULP IMPLANTATION
 SCAFFOLD IMPLANTATION
 INJECTABLE SCAFFOLD DELIVERY
 THREE DIMENSIONAL CELL PRINTING
 GENE THERAPY
 DISINFECTION PROTOCOLS
 FUTRE ASPECTS
 CONCLUSION
 REFERENCES
stem cell markers j clin exp dent.
2012;4(1):e66-71.

 DPSCs: STRO-1, CD 146, STRO-4, Osteocalcin, Oct-4, Nanog,

SSEA-3, SSEA-4,Nestin, TRA 1-60, TRA 1-81.

 SHED: STR0-1, CD 146.

 SCAP: DSP, BSP, ALP, CD 105.

 PDLSCS: CD 146, CD 105, CD 166, STRO-1, MUC-18.

 DFPCS: Notch-1, STRO-1, Nestin

 Cell Homing for Pulp Regeneration

 The cell homing strategy for pulp regeneration relies on signalling

molecules for the migration, proliferation and differentiation of
stem/progenitor cells (Kim et al. 2012).

 This approach can be more clinically translatable compared with the

cell-based approach because there is no need for cell isolation and
expansion processes
 A major concern in pulp regeneration through cell homing strategy is
stem cell sources.
 The possible cell sources for pulp regeneration through cell homing
include dental pulp stem cells (DPSCs), stem cells from apical papilla
(SCAP), and bone marrow stem cells (BMSCs), and others.

 SCAP might be another possible cell source for pulp

regeneration.
 Apical papilla is apical to the epithelial diaphragm
of the immature teeth, and it has the collateral
circulation. 
Figure 1. Cell homing: (a) infected root
canal; (b) cleaned and prepared root canal;
(c) transplantation of scaffold with growth
factors; (d) attraction of stem cells from
perivascular niche
 Cell homing /Cell-free Approaches

 Three clinical procedures should be

performed if cell homing is applied in
endodontic treatment :
 (i) root canal disinfection and
apical foramen enlargement;
 (ii) transplantation of bioactive
scaffold with signaling molecules,
and tooth restoration;
 (iii) regular follow-up to check the
viability (neovascularization and re-
innervation) of the regenerated
pulp.
clinically viable protocol of a cell-homing approach
 Cell-based approach

Nakashima et al has been tried to prove the

safety, efficacy and feasibility of stem cell
transplantation in the root canal over a
decade.

a protocol should follow the good

manufacturing practice (GMP) guidelines,
however excessive costs will make it difficult to
implement in clinics
Potential technologies for regenerative
endodontics

12
1. Root canal revascularization via blood
clotting,
2. Postnatal stem cell therapy,
3. Pulp implantation,
4. Scaffold implantation,
5. Injectable scaffold delivery,
6. Three-dimensional cell printing, and
7. Gene delivery
ROOT CANAL REVASCULARIZATION VIA BLOOD
CLOTTING

 A novel concept of revascularization of immature nonvital, infected teeth

was recently introduced.
 It was introduced by Ostby in 1961,
 In 1966, Rule and Winter documented root development and apical
barrier formation in cases of pulpal necrosis in children
 In 1972, Ham et al demonstrated apical closure of immature pulp less
teeth in monkeys

15
 In 2001 Iwaya et al and in 2004 Banchs and Trope demonstrated the
advantages of this treatment modality, which resulted in a
radiographically apparent normal maturation of the entire root versus an
outcome of only a calcific barrier formation at the apex after conventional
calcium hydroxide–induced apexification.

16
Garcia-Godoy and Murray suggested the following guidelines for
tooth regeneration:

1) The tooth should undergo necrosis without indication for apexogenesis,

apexification, partial pulpotomy, or endodontic treatment;

2) The tooth should be permanent, immature, and with open apex the tooth should
have thin root walls that benefit from the continuous root development to become
stronger and less susceptible to future fracture;

3) The patient should age between 7 and 16 years, have good health. The parents or
legal responsible should be aware that the treatment demand multiple
appointments;

4) The parents or legal responsible should be aware that pulp regeneration is an

experimental treatment and standardized protocols are not available;
5) The patient should be aware about tooth staining due to the use of the
antibiotic paste;

6) A anesthetics without vasoconstrictor should be used to induce bleeding inside

root canal;

7) MTA or calcium hydroxide layer should be dressed above the blood clot;

8) The endodontic sealers are not biocompatible with regeneration and should not
be used;

9) The tooth should be restored with resin-modified glass ionomer, resin composite
overlay, or full crown to prevent microleakage, depending on the degree of crown
structure loss.
 Requirements for developing successful
regenerative endodontic techniques:

►Etiology of loss of vitality:

►Diameter of apex
►Disinfection
►Removal of smear layer
Are all immature permanent teeth with necrotic pulps indicative
for RET?

According to the ‘Clinical Considerations for a Regenerative Procedure’

suggested by AAE, RET is recommended for teeth with a necrotic pulp
and an immature apex.

Based on Cvek's classification of root

development (Cvek 1992),
the stage 1 (less than 1/2 of root formation with open apex),

stage 2 (1/2 root formation with open apex)

stage 3 (2/3 of root development with open apex)

Are suitable for RET because of the short root, thin canal
walls and wide‐open apex as apexification has no potential for
root maturation (thickening of the canal walls and/or
continued root development).
Immature permanent teeth at stage 4 (nearly
completed root formation with open apex) can
be managed with either RET or an apical MTA
plug and root canal filling because the canal
walls have enough thickness and strength.

Immature permanent teeth with a necrotic pulp

requiring post for adequate coronal restoration are
not suitable for RET and better treated with apical
MTA plug and root canal filling
Disinfection vs regeneration
 Smear layer

 Complete removal of smear layer – for the adherence of the stem cells to
the root canal walls
 17% solution of ethylene diaminetetraacetic acid (EDTA) is applied as a
final flush.
 citric acid
 MTAD are also used for smear layer removal.
 MTAD is an aqueous solution of 3% doxycycline, 4.25% citric acid, and
0.5% polysorbate 80 detergents.
The American Association of Endodontists (AAE 2016) clinical considerations for
regenerative endodontic procedures define success by three measures:

Primary goal (essential): The elimination of symptoms and the evidence of bony
healing
Secondary goal (desirable): Increased root wall thickness and/or increased root
length
Tertiary goal: positive response to vitality testing
THE AMERICAN ASSOCIATION OF ENDODONTISTS (AAE)
REGENERATIVE ENDODONTICS COMMITTEE CREATED A
DOCUMENT TITLED ‘‘CONSIDERATIONS FOR REGENERATIVE
PROCEDURES’’

necrotic pulp and an immature apex in which

pulp space is not needed for post/core and the
patient is compliant

Case Selection . Kling et al showed that reimplanted teeth with

apices larger than 1 mm were more likely to be
revascularized.

600-fold increase (vs circulating blood) in

CD73 and CD105, which are markers for
mesenchymal stem cells
 As with all endodontic procedures,
patients/parents should be informed that there
is a possibility of pain and/or swelling after the
procedure and that there may be a lack of
response to treatment

Informed Consent

other treatment options for immature teeth

with open apices, including apexification, no
treatment, or extraction.
 First Appointment

Rubber dam

Acess opening
Irrigation
Pressure alteration devices[The endovac]

the AAE considerations recommend lower

concentrations of NaOCl

no mechanical debridement of the canal

space.

an intracanal medicament be placed. The

medicament can be placed using a Lentulo
spiral, syringe, or Micro-Apical Placement
Ruparel et al have shown that higher
concentrations of TAP have a detrimental effect
on stem cell survival; therefore, it seems
prudent to use diluted concentrations of the
antibiotics

that all concentrations of calcium hydroxide

promoted stem cell survival

The length of time between the first and final

appointments has varied from 1 week
 Mechanism of
Revascularization
 It is possible that a few vital pulp cells remain at the apical end of the root canal

 These cells might proliferate into the newly formed matrix and differentiate into
odontoblasts under the organizing influence of cells of Hertwig’s epithelial root
sheath, which are quite resistant to destruction, even in the presence of
inflammation .

 The newly formed odontoblasts can lay down atubular dentin at the apical end,
causing apexogenesis (elongation of root), as well as on lateral aspects of
dentinal walls of the root canal, reinforcing and strengthening the root.

39
 Another possible mechanism of continued root development could be due
to

 Multipotent dental pulp stem cells, which are present in permanent teeth
and might be present in abundance in immature teeth.

 These cells from the apical end might be seeded onto the existing dentinal
walls and might differentiate into odontoblasts and deposit tertiary or
atubular dentin.

40
 The third possible mechanism could be attributed to the presence of
stem cells in the periodontal ligament , which can proliferate, grow into the
apical end and within the root canal, and deposit hard tissue both at the
apical end and on the lateral root walls.

 The evidence in support of this hypothesis is presented by documentation

of cementum and Sharpey’s fibers in the newly formed tissues.

41
 The fourth possible mechanism of root development could be
attributed to stem cells from the apical papilla or the bone marrow.

 Instrumentation beyond the confines of the root canal to induce bleeding

can also transplant mesenchymal stem cells from the bone into the canal
lumen.

 Transplantation studies have shown that human stem cells from bone
narrow can form bone or dentin in vivo

42
 Another possible mechanism could be that the blood clot itself, being a rich source
of growth factors, could play an important role in regeneration.

1. Platelet-derived Growth Factor,

2. Vascular Endothelial Growth Factor (Vegf ),
3. Platelet-derived Epithelial Growth Factor, And
4. Tissue Growth Factor and

could stimulate differentiation, growth, and maturation of fibroblasts,

odontoblasts, cementoblasts, etc from the immature, undifferentiated mesenchymal
cells in the newly formed tissue matrix

43
 Advantages

 It requires a shorter treatment time; after control of infection,

 It is also very cost-effective, because the number of visits is reduced,
 no additional material (such as TCP, MTA) is required.
 Obturation of the canal is not required unlike in calcium hydroxide–
induced apexification, with its inherent danger of splitting the root during
lateral condensation.

 However, the biggest advantage is that of achieving continued root

development (root lengthening) and strengthening of the root as a result of
reinforcement of lateral dentinal walls with deposition of new dentin/hard
tissue
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 This approach is technically simple and can be completed using
currently available instruments and medicaments without expensive
biotechnology.

 The regeneration of tissue in root canal systems by a patient’s own blood

cells avoids the possibility of immune rejection and pathogen
transmission from replacing the pulp with a tissue engineered construct.
Andreasen and Bakland (80) based on an analysis of more than 1200
traumatized teeth and 370 autotransplanted premolars provides additional
information regarding possible outcomes. They described 4 types of healing
outcomes:

1. Revascularization of the pulp with accelerated dentin formation leading

to pulp canal obliteration
2. Ingrowth of cementum and periodontal ligament (PDL)
3. Ingrowth of cementum, PDL, and bone
4. Ingrowth of bone and bone marrow
Chen et al followed 20 teeth that had undergone REPs and
described 5 types of responses:

1. Increased thickening of the canal walls and continued root maturation

2. No significant continuation of root development with the root apex
becoming blunt and closed
3. Continued root development with the apical foramen remaining open
4. Severe calcification (obliteration) of the canal space
5. A hard-tissue barrier formed in the canal between the coronal MTA
plug and the root apex

Considerations for Regeneration Procedures Alan S. Law, DDS, PhD.

JOE — Volume 39, Number 3S, March 2013
 Effects of medicaments and irrigants

 Triple antibiotic paste was also tested for its effect on the survival of
stem cells from the apical papilla in vitro (Ruparel et al. 2012,
Althunairy et al. 2014).
 It is recommended to use triple antibiotic paste at a concentration no
greater than 1 mg mL−1 (0.1–1 mg mL−1) in RET (AAE 2016) to avoid
damage of stem cells from the apical papilla.

Tetracycline enhances the growth of host cells on dentin,

not by an antimicrobial action, but via exposure of
embedded collagen fibers or growth factors .
 However, it is not yet know if minocycline shares this effect and whether
these additional properties might contribute to successful
revascularization.

17%EDTA acts to demineralize the dentine and expose

the dentine matrix to release growth factors
(Yamauchi et al. 2011, Galler et al. 2015, 2016).

49
When citric acid (ph 1.8) is used to demineralize root
canal dentine and release tgf-b1, a more active form of
tgf-b1 may be present, in turn, leading to a greater
biologic effect on stem cells.

A) Flattened pulp cells attached to cleaned

and shaped dentin after the use of
Aquatine EC and MTAD.
. ( (B) Rounded pulp cells attached to cleaned and
shaped dentin after the use of NaOCl and MTAD.
(C) Oval pulp cells attached to the root canal smear
layer after the use of NaOCl.
 Histological outcome

Nygaard‐Ostby (1961) and Nygarrd‐Ostby & Hjortdal (1971) were the

pioneers who attempted to regenerate the pulp tissue in the
disinfected, unfilled root canal space of teeth using a blood clot.

However, even in virgin immature teeth of animals and humans

without pulpal and periapical disease after RET, bone‐, and
cementum‐like tissues and no pulp/dentine‐like tissue are
formed in the disinfected canal space (Torabinejad et al. 2014,
Nosrat et al. 2015).
 Positive response to vitality testing

It has been demonstrated that a human immature permanent tooth with

apical periodontitis after RET regained pulp sensibility (Banchs & Trope 
2004)

However, histologic and immunohistochemical findings of a

human immature permanent tooth with apical periodontitis
after regenerative endodontic therapy revealed cementum‐like,
bone‐like and nerve fibres in the canal even though the vital
tissue was not pulp tissue (Lei et al. 2015).
 Nerve regeneration may be attributed to
several mechanisms:

First possible mechanism Growth factors

Transforming growth factor beta regulates mitogenic effects of other
growth factors (nerve growth factor and brain-derived neurotrophic
factor),

Second hypothesized mechanism Dental pulp stem cells have the potential to differentiate into
neuronal cells and can induce axon guidance

The third hypothesized Stem cells might differentiate from the periodontal ligament. Express
mechanism the markers of undifferentiated neural crest cells

The fourth possible mechanism: Relies on bone marrow mesenchymal stem cells, which can
differentiate into neurons and astrocytes under appropriate
conditions .
Is RET a regenerative or reparative process?

 The damaged pulp tissue in the canal space of immature teeth after RET is
replaced by bone‐, cementum‐, and periodontal ligament‐like tissue.
Therefore, RET is considered a reparative and not a regenerative process
histologically (lin & rosenberg 2011, simon et al.
Biological function of ectopic cementum‐, and bone‐like tissues in the canal
space

The biological behavior of ectopic cementum‐like or bone‐like tissue in the

canal space of immature permanent teeth with necrotic pulp after RET
remains to be seen in long‐term follow‐up.
 Is RET successful?

Recent systematic reviews showed that the success rate for resolution of
periapical pathosis was reliably achieved (91%) with RET (Tong et al. 
2017, Torabinejad et al. 2017).

Secondary outcomes of increased root

development (80%) and apical closure (76%)
were more variable results.
 Adverse effects

Failed cases are primarily attributed to

inadequate removal of biofilm possibly due to
minimal instrumentation (lin et al. 2014) or
inadequate disinfection 

Presence of osseous tissue in the root canal

system observed in the repair process may be
controversial (andreasen & bakland 2012).

Raises the concern how to treat root canal calcification of

immature permanent teeth with failed revascularization.
Few limitations of revascularization

 Long-term clinical results are yet not available.

 It is possible that the entire canal might be calcified, compromising esthetics

and

 potentially increasing the difficulty in future endodontic procedures if required.

 In case post and core are the final restorative treatment plan, revascularization is
not the right treatment option because the vital tissue in apical two thirds of the
canal cannot be violated for post placement.

59
 Concept of sealbio

A regeneration based ,non obturation root canal treatment for fully mature teeth
Postnatal Stem Cell Therapy /cell
based approach

 The simplest method to administer cells of appropriate regenerative potential is

to inject postnatal stem cells into disinfected root canal systems after the apex is
opened.

 Postnatal stem cells can be derived from multiple tissues, including skin, buccal
mucosa, fat, and bone

63
 A major research obstacle is identification of a postnatal stem cell source capable
of differentiating into the diverse cell population found in adult pulp (e.g.,
fibroblasts, endothelial cells, odontoblasts).

 Technical obstacles include the development of methods for harvesting and any
necessary ex vivo methods required to purify and/or expand cell numbers
sufficiently for regenerative endodontic applications
 One possible approach would be to use dental pulp stem cells derived from
1. Autologous (patient’s own) cells buccal mucosal biopsy, or umbilical
cord stem cells that have been cryogenically stored after birth;
2. Allogenic purified pulp stem cell line that is disease- and pathogen-free;
3. Xenogneic (animal) pulp stem cells that have been grown in the
laboratory.

 It is important to note that no purified pulp stem cell lines are presently
available,

 The mucosal tissues have not yet been evaluated for stem cell therapy.

65
 ADVANTAGES

 First, autogenous stem cells are relatively easy to harvest and to

deliver by syringe

 The cells have the potential to induce new pulp regeneration.

 Second, this approach is already used in regenerative medical

applications including bone marrow replacement, and several
potential endodontic applications

66
DISADVANTAGES

 The cells may have low survival rates.

 The cells might migrate to different locations within the body , possibly leading to
aberrant patterns of mineralization.

A solution for this latter issue may be to apply the cells together with a fibrin clot
or other scaffold material. This would help to position and maintain cell
localization.

67
PULP IMPLANTATION

68
 The majority of in vitro cell cultures grow as a single monolayer attached to
the base of culture flasks. However, some stem cells do not survive unless they
are grown on top of a layer of feeder cells .

 The stem cells are grown in two dimensions.

 To take two-dimensional cell cultures and make them three-dimensional, the

pulp cells can be grown on biodegradable membrane filters.

 Many filters will be required to be rolled together to form a three dimensional

pulp tissue, which can be implanted into disinfected root canal systems.

69
 The advantages of this delivery system are that the cells are relatively easy
to grow on filters in the laboratory.

 The growth of cells on filters has been accomplished for several decades,
as this is how the cytotoxicity of many test materials is evaluated .

 Moreover, aggregated sheets of cells are more stable than dissociated cells
administered by injection into empty root canal systems

70
 The source of pulp tissue may be a purified pulp stem cell line that is disease or
pathogen-free, or is created from cells taken from a biopsy, that has been grown
in the laboratory.

 The cultured pulp tissue is grown in sheets in vitro on biodegradable polymer

nanofibers or on sheets of extracellular matrix proteins such as collagen I or
fibronectin

 So far, growing dental pulp cells on collagens I and III has not proved to be
successful , but other matrices, including vitronectin and laminin, require
investigation.

71
 The potential problems associated with the implantation of sheets of cultured
pulp tissue is that

 Specialized procedures may be required to ensure that the cells properly adhere to
root canal walls.

 Sheets of cells lack vascularity, so only the apical portion of the canal systems
would receive these cellular constructs, with coronal canal systems filled with
scaffolds capable of supporting cellular proliferation .

 Because the filters are very thin layers of cells, they are extremely fragile, and this
could make them difficult to place in root canal systems without breakage.

72
 Cells located more than 200 µ m from the maximum oxygen
diffusion distance from a capillary blood supply are at risk of anoxia
and necrosis

 The development of this endodontic tissue engineering

therapy appears to present low health hazards to patients,
although concerns over immune responses and the possible
failure to form functioning pulp tissue must be addressed
through careful in vivo research and controlled clinicaltrials.
SCAFFOLD IMPLANTATION

74
Pulp STEM cells ORGANIZED into a three dimensional

structure

Supports cell organization and vascularisation

IMPLANTED SURGICALLY
NATURAL
1. Collagen
2. Tricalcium phosphate
3. Hydroxy apatite

SYNTHETIC
Polylactic acid (PLA),
Polyglycolic acid (PGA),
Polycaprolactone (PCL),
 Rigid tissue engineered scaffold structures provide excellent support for
cells used in bone and other body areas where the engineered tissue is
required to provide physical support .

 However, in root canal systems a tissue engineered pulp is not required to

provide structural support of the tooth.

 This will allow tissue engineered pulp tissue to be administered in a soft

three-dimensional scaffold matrix, such as a polymer hydrogel.

78
 Requirements of injectable scaffolds

The injectability is generally related to the

rheological properties of the monomers or pre-
polymers
This transition can be stimulated by changes
in temperature, pH, light, enzyme, or the
Injectability addition of a crosslinking agent. 

As for other injectable scaffolds such as

microspheres, the concentration, particle size,
degree of aggregation, and surface charge, are
critical factors to affect injectability.
  natural polymers, they are usually considered
non-toxic,

synthetic hydrogels, however, cytotoxicity is a

 Cytotoxicity 
major 

To date, only PLA, PEG, and PLGA have been approved

by the FDA for clinical applications.

Host responses towards a biomaterial is

Host responses pivotal for a biomaterial, 
 Depends on the original rigidity of the polymer
chains, types of crosslinking molecules,
Mechanical properties  crosslinking density, and swelling as a result of
the hydrophilic/hydrophobic balance

Injectable hydrogels are soft and elastic due to their

thermodynamic compatibility with water
 Increasing crosslinking density improves both
the stiffness and toughness of the hydrogel.
However, the degradation time of the hydrogel
degradation
with high crosslinking density is also
prolonged. 
 Heparin, a negatively charged glycosaminoglycan, can bind
growth factors, protect them from proteolytic degradation,
and make them available to cells as they disintegrate and
remodel the extracellular matrix.

Cell-free Approaches for Dental Pulp Tissue Engineering Kerstin M. Galler, DDS, PhD, Andreas Eidt, and
Gottfried Schmalz, DDS, PhD. JOE — Volume 40, Number 4S, April 2014
Short peptide molecules are designed to
undergo self assembly into nanofibrous
structures because of electrostatic and
hydrophilic-hydrophobic interactions

The nanofibers that form upon self-assembly

of the peptide monomers trap water and thus
form gels.

This way the cross-linking mechanism,

fiber length, and viscoelasticity can be
modified .
 Types of injectable scaffolds

There are two types of injectable scaffolds:

hydrogels
microspheres.

  
   Hydrogen bond crosslinked hydrogels 
 Temperature-induced hydrogels
  Chemically crosslinked hydrogels 
 Reversible chemically crosslinked hydrogels
 Microspheres 

 microspheres allow cells to adhere and

proliferate on the microspheres in vitro for
some period of time prior to injecting the
construct to the defective area, which is an
advantage for certain applications.

The incorporation of microspheres into

hydrogels increases the mechanical strength
and porosity of the hydrogels 
 In pulp-exposed teeth, dentin chips have been found to
stimulate reparative dentin bridge formation .

 Dentin chips may provide a matrix for pulp stem cell

attachment and also be a reservoir of growth factors .

 The natural reparative activity of pulp stem cells in

response to dentin chips provides some support for the
use of scaffolds to regenerate the pulp dentin complex

88
 Hydrogels are injectable scaffolds that can be delivered
by syringe .

 Hydrogels have the potential to be noninvasive and easy to deliver into root canal
systems.

 The hydrogel may promote pulp regeneration by providing a substrate for cell
proliferation and differentiation into an organized tissue structure

 Past problems with hydrogels included limited control over tissue formation and
development, but advances in formulation have dramatically improved their
ability to support cell survival

89
 Despite these advances, hydrogels are at an early stage of research, and
this type of delivery system, although promising, has yet to be proven to be
functional in vivo.

 To make hydrogels more practical, research is focusing on making them

photo polymerizable to form rigid structures once they are implanted into
the tissue site .

90
 Smart Scaffolds

Scaffolds with the ability to deliver biochemical factors at a

predetermined rate for a definitive time period.
Advantages

 Early capillary invasion

 Induce osteoblastic differentiation of existing progenitor cells in
recipient tissue.
 May enhance cell penetration, proliferation, differentiation and
bone matrix production and improve vascularization of grafts
THREE-DIMENSIONAL CELL
PRINTING

92
 The final approach for creating replacement pulp tissue may be to
create it using a three-dimensional cell printing technique.

 An ink-jet-like device is used to dispense layers of cells suspended in

a hydrogel to recreate the structure of the tooth pulp tissue.

 The three-dimensional cell printing technique can be used to precisely

position cells .

 This method has the potential to create tissue constructs that mimic
the natural tooth pulp tissue structure

93
 The disadvantage is that careful orientation of the pulp tissue construct
according to its apical and coronal asymmetry would be required during
placement into cleaned and shaped root canal systems.

 However, early research has yet to show that three-dimensional cell

printing can create functional tissue in vivo

94
Bioprinting of three-dimensional dentin–pulp complex with local
differentiation of human dental pulp stem cells
Jonghyeuk Han, Da Sol Kim, [...], and Hyun-Wook Kang. JOURNAL OF
TISSUE ENGINEERING

CBCT
DATA CODING
BIO PRINTING USING INKS

 Two bio-inks, F5- and f20-bio-ink, for spatial

control of odontogenic differentiation of
hdpscs for the production of dentin–pulp
complexes.
GENE THERAPY

Gene therapy, a relatively new frontier of

medicine, has emerged as a viable and
promising strategy that obviates the
delivery of exogenous molecules
97
►A carrier referred to as a vector is employed to introduce the therapeutic gene into
the patient’s target cells.
► The vector can be given intravenously or injected directly into a particular tissue
within the body, where it is taken up by the concerned target cells.
►Or else, the patient’s sample cells are removed and exposed to the vector in a
laboratory setting; the cells containing the vector are then reintroduced into the
patient.

98
 New techniques involving viral or nonviral vectors can deliver genes for
growth factors, morphogens, transcription factors, and extracellular matrix
molecules into target cell populations, such as the salivary gland.

Viral or non viral

plasmids,
Retroviruses,
peptides,
Adenovirus,
gene guns,
Adeno associated virus,
DNA-ligand complexes,
Herpes simplex virus,
electroporation,
Lentivirusv
sonoporation, and cationic liposomes 99
ADVANTAGES OF GENE THERAPY:
1) May avoid cleaning and shaping root canals
2) May avoid the need to implant stem cells.

DISADVANTAGES:
1) Most cells in necrotic teeth are already dead
2) Difficult to control
3) Risk of health hazards
4) Not approved by the FDA.
With this approach, genes encoding the desired signaling molecules
including growth factors, morphogens, transcription factors, and
ECM molecules are delivered by viral or nonviral vectors into target
somatic cells to induce a series of biological responses that
contribute to the regeneration of the target tissue.
yang and colleagues successfully transfected
rat STRO-1 selected DPSCs with the human
BMP-2 gene by utilizing adenoviral vectors.

However, a literature search found a lack of

evidence in this field and gene therapy has yet
to prove its efficacy in rescuing necrotic tooth
pulp as part of dentin/pulp regenerative
treatment 
Regenerative Endodontic Treatment with Orthodontic Treatment in a
Tooth with Dens Evaginatus: A Case Report with a 4-year Follow-up
Marianella Natera, BDS, DMD, MSD,* and Padma M. Mukherjee,
BDS, DMD, PhD†. JOE — Volume -, Number -, - 2018
In the present case, TAP was used in a pasty consistency, possessing a high concentration of
metronidazole, ciprofloxacin, and minocycline. In vitro studies have shown that the
concentration of antibiotics is inversely proportional to the survival and proliferation of
stem cells of the apical papilla . This may have also contributed to the lack of root
development
Analysis of the rate of maturogenesis of a traumatized Cvek's stage
3 anterior tooth treated with platelet-rich fibrin as a regenerative
tool using three-dimensional cone-beam computed tomography: An
original case report

Raji Viola Solomon1, Umrana Faizuddin1, Sushma Shravani Guniganti1, 

Shefali Waghray2
Low-intensity laser phototherapy enhances the proliferation of dental
pulp stem cells under nutritional deficiency
Braz. Oral Res. 2016;30(1):e80

 660-nm wavelength continuous wave diode laser .

 LPT can increase the growth of different cellular lineages

when exposed to nutritional deficiency.

 LPT can increase the growth of different cellular lineages

when exposed to nutritional deficiency.

 Therefore, LPT could be relevant as the adjunctive therapy for

tissue engineering.
 FUTURE ASPECTS
Whole tooth regeneration as a future organ replacement
regenerative therapy
Case reports
4 months follow up
 conclusion

 Regenerative endodontics is one of the most exciting developments in

dentistry today and endodontists are at the forefront of this cutting-edge
research.

 Endodontists’ knowledge in the fields of pulp biology, dental trauma and

tissue engineering can be applied to deliver biologically based regenerative
endodontic treatment of necrotic immature permanent teeth resulting in
continued root development, increased thickness in the dentinal walls and
apical closure.
►For greater regenerative potential to be met, investigators must perform
much more research and development.

► Translational research is crucial in making these procedures more

predictable while pushing the boundaries of future procedures that are likely to
involve the direct clinical manipulation of scaffolds, growth factors, and stem
cells.
 references

1. Clinical Approaches in Endodontic Regeneration. Current and Emerging

Therapeutic Perspectives Henry F. Duncan Paul Roy Cooper Editors.
2. Regenerative Endodontics: A Review of Current Status and a Call for Action. Peter
E. Murray, BSc(Hons), PhD,* Franklin Garcia-Godoy, DDS, MS,† and Kenneth M.
Hargreaves, DDS, PhD‡. JOE — Volume 33, Number 4, April 2007
3. Treatment Strategy for Guided Tissue Regeneration in Combined Endodontic-
Periodontal Lesions: Case Report and Review.Se-Lim Oh, DMD MS,* Ashraf F.
Fouad, BDS, DDS, MS,† and Sang-Hoon Park, DDS, MS‡. JOE — Volume 35,
Number 10, October 2009.
4. Treatment of the Immature Tooth with a Non–Vital Pulp and Apical Periodontitis
Martin Trope, DMDa,b,. Dent Clin N Am 54 (2010) 313–324
5. The Hidden Treasure in Apical Papilla: The Potential Rolein Pulp/Dentin
Regeneration and BioRoot EngineeringGeorge T.-J. Huang, DDS, MSD, DSc,*
Wataru Sonoyama, DDS, PhD,§ Yi Liu, DDS, PhD,‡He Liu, DDS, PhD, Songlin
Wang, DDS, PhD,‡ and Songtao Shi, DDS, PhD†