The potential use of ascorbic acid to recover the cellular senescence of lipopolysaccharide-induced human apical papilla cells: an in vitro study.

OBJECTIVES: To examine the effect of lipopolysaccharide (LPS) on cellular senescence induction of human apical papilla cells (hAPCs) and evaluate the potential use of 50 µg/ml ascorbic acid to recover cellular senescence and regenerative functions. MATERIALS AND METHODS: hAPCs were treated with LPS at 1 and 10 µg/ml either with or without 50 µg/ml ascorbic acid for 48 h. The cellular senescence biomarkers were analyzed by senescence-associated ß-galactosidase (SA-ß-gal) staining and senescence-related gene expression, p16 and p21. Cell migration, at 12 h and 24 h, was evaluated using a scratch wound assay. Mineralization potential was assessed at 21 days using Alizarin red S staining and dentine sialophosphoprotein (DSPP) and bone sialoprotein (BSP) gene expression. RESULTS: 1 µg/ml and 10 µg/ml LPS stimulation for 48 h induced cellular senescence, as shown by remarkable SA-ß-gal staining and p16 and p21 gene expression. The percentage of wound closure and mineralized formation was reduced. The co-incubation with ascorbic acid significantly down-regulated the level of SA-ß-gal staining. The reduction of senescence-associated gene expressions was observed. Ascorbic acid improved cell migration, mineralized nodule formation, and the expression of DSPP and BSP genes in LPS-treated hAPCs. CONCLUSIONS: LPS significantly promoted cellular senescence on hAPCs and diminished the cell function capacity. Co-presence of ascorbic acid could impede cellular senescence and possibly improve the regenerative capacity of LPS-induced senescent hAPCs in vitro. CLINICAL RELEVANCE: The data support the in vitro potential benefit of ascorbic acid on cellular senescence recovery of apical papilla cells.

Apexification with a bioceramic reparative cement: a case report.

The aim of this case report is to describe the treatment of a maxillary right central incisor with pulpal necrosis and incomplete root formation. The 14-year-old patient had experienced trauma to both maxillary central incisors approximately 2 years earlier. Therapy consisted of apexification with a bioceramic reparative cement to form an apical plug. After the clinical and radiographic evaluations, the clinician opened the crown, performed the chemical-mechanical preparation, and placed calcium hydroxide-based medication. At the next appointment, 24 days later, the intracanal medication was removed through passive ultrasonic instrumentation; the canal was dried; and the bioceramic cement was inserted into the apical portion with the aid of a mineral trioxide aggregate holder. A sterile cotton ball, moistened with distilled water, was used to maneuver the material in the apical region, and a periapical radiograph was exposed to confirm the correct placement of the bioceramic reparative cement. The canal was filled with gutta percha cones and a bioceramic root canal sealer. All procedures were performed with the aid of microscopic magnification. Clinical and radiographic evaluations at the 18-month follow-up visit showed that the treated tooth was asymptomatic, suggesting that the bioceramic reparative cement is effective for apexification.

Are platelet concentrate scaffolds superior to traditional blood clot scaffolds in regeneration therapy of necrotic immature permanent teeth? A systematic review and meta-analysis.

BACKGROUND: The effectiveness of platelet concentrates in promoting root development of necrotic immature permanent teeth is unclear. The present study evaluated whether the platelet concentrate protocol was superior to the traditional blood clot protocol in regeneration therapy. METHODS: We searched Electronic databases, such as PubMed, Cochrane Library, ClinicalTrials and EMBASE. Randomized controlled trial studies, cohort studies, case-control studies and cross-sectional studies were included, in which platelet-rich concentrates were tested for periapical healing and root development, with the blood clot treatment protocol as the control group. Clinical and radiographic outcomes were considered. Selected articles were assessed for risk of bias. Pooled risk ratios (risk ratio, RR) were calculated for clinical success, responses to cold and electric pulp tests, periapical lesions, apex closure, root lengthening, and thickening of the dentin walls. Subgroup meta-analysis were conducted according to the type of platelet concentrate used. RESULTS: Of the 1272 screened studies, 13 randomized controlled studies, 2 case-control studies and 1 cohort study were selected, in which 465 immature necrotic permanent teeth, particularly incisors and premolars, were treated. Of these 465 teeth, 457 (98.2%) in both the control and experimental groups remained clinically asymptomatic for the entire study duration, whereas eight (1.8%) showed signs and symptoms of failure, including spontaneous pain, sensitivity to percussion or reinfection. Compared with control teeth, teeth treated with PRP achieved better apical healing than BC group (RR 1.13, 95% CI 1.01-1.26, P = 0.03), and teeth treated with platelet concentrates showed improved apical closure (RR 1.04, 95% CI 0.86-1.25, P = 0.69), root lengthening (RR 1.01, 95% CI 0.74-1.39, P = 0.93), and thickening of the dentin walls (RR 1.35, 95% CI 0.95-1.93, P = 0.09), although these differences were not statistically significant. CONCLUSIONS: Platelet concentrates can be used as successful scaffolds for regenerative endodontic treatment of necrotic immature permanent teeth, and PRP as a scaffold may achieve better periapical healing of teeth with periapical inflammation, although they did not differ significantly from conventional blood clot scaffolds in development of the root.

Apical pressures generated by several canal irrigation methods: A laboratory study in a maxillary central incisor with an open apex.

AIM: A laboratory study to determine the apical pressure generated by seven canal irrigation methods in an anterior tooth with an open apex. METHODOLOGY: Canal irrigation was performed on a 3D-printed central maxillary incisor with an open apex (maximum diameter of 2.1 mm). Ultrasonically activated irrigation (UAI), sonic activation (EDDY), negative pressure irrigation (EndoVac), the self-adjusting file (SAF) and the XP-endo Finisher were employed at tooth length (TL), TL-1 mm, TL-2 mm and TL-3 mm. UAI was tested at three intensity levels additionally. Hydrodynamic irrigation with RinsEndo was performed in the pulp chamber, at the canal orifice, the coronal third, the middle of the canal and at TL. Er:YAG laser activation, at four frequency settings, was performed in the pulp chamber and at the orifice of the canal. The pressure of the fluid towards the canal terminus generated by activation was directly transferred to a pressure sensor with a range of 0 to 120 mmHg and a response time of ≤0.5 ms. The critical threshold for apical extrusion of the irrigant was set at 5.73 mmHg (lower limit of the central venous pressure: 5.88 ± 0.15 mmHg). Each experiment was repeated ten times. The tests were followed by descriptive analyses (maximum, mean, standard deviation, 95% confidence interval). RESULTS: EndoVac, the SAF, the XP-endo Finisher, and UAI never exceeded the critical threshold at any insertion depth or intensity level. Er:YAG laser activation exceeded the critical threshold exclusively at frequency settings that varied from the manufacturer's recommendation. EDDY at TL and RinsEndo at any insertion depth exceeded the critical threshold in 100% of the measurements. EDDY at TL-1,-2, and-3 mm crossed the critical threshold in 30%, 10%, and 20% of the measurements, respectively. CONCLUSIONS: In a simulated maxillary central incisor with an open apex, irrigation with EndoVac, Er:YAG laser activation, UAI, the SAF, and the XP-endo Finisher generated apical pressures below the critical threshold of 5.73 mmHg. By contrast, using EDDY and RinsEndo for irrigation produced higher apical pressures that exceeded the critical threshold.

Effect of revascularisation and apexification procedures on biomechanical behaviour of immature maxillary central incisor teeth: a three-dimensional finite element analysis study.

OBJECTIVES: This study aimed to assess the effects of revascularisation and apexification procedures on biomechanical behaviour of immature teeth using 3-dimensional finite element analysis (3D FEA). MATERIALS AND METHODS: Five 3D FEA permanent maxillary incisor models were developed from CBCT scans and available literature data: Model MT: Mature tooth, Model IT: Immature tooth (Cvek's stage 3), Model AT: Apexified tooth-mineral trioxide aggregate (MTA) apexification, Model RTB: Revascularised tooth with blood, and Model RTS: Revascularised tooth with supplementary scaffold. Using FEA, a masticatory load of 240N at 120° was simulated, and the Von Mises and maximum principal stresses within the models were evaluated. Failure index (FI) and weakening% were also calculated for each model. RESULTS: On dentinal stress analysis, model MT (96.16MPa) and IT (158.38MPa) had lowest and highest stress values, respectively. Among the experimental groups, model RTS (131.12MPa) had lower stresses than AT (136.33MPa) and RTB (133.7MPa), with no significant difference among the three. Peak dentinal stresses in all the models were observed in the cervical third of the root and near the apical opening in model IT. The extent of high dentinal stress area in model RTB and RTS was lesser than that of AT. The FI and weakening% values were highest for model AT followed by RTB and RTS, among the experimental groups. However, all these treatments strengthened an immature tooth by more than 20%. CONCLUSIONS: AT, RTB, and RTS treatments lowered the stress values and risk of fracture in immature teeth with no significant difference among the three groups. CLINICAL RELEVANCE: Stress distribution evaluation following revascularisation/apexification was essential, with potential to influence clinical decision-making. MTA apexification and revascularisation with blood clot/supplementary scaffold lowered the stresses in immature teeth, with no significant difference among the three.

Treatment of immature teeth with nonvital pulps in adults: a prospective comparative clinical study comparing MTA with Ca(OH)2.

AIM: To evaluate and compare the influence of various predictors on outcomes of apexification using either mineral trioxide aggregate (MTA) or calcium hydroxide (CH) in permanent immature anterior teeth with necrotic pulps and periapical lesions of adults. METHODOLOGY: Ninety immature teeth with necrotic pulps and periapical lesions on adult patients (aged 18-40 years) were treated with MTA (45 teeth) or CH (45 teeth) between 2015 and 2018. Patients of both groups were recalled for follow-up examinations after the first intervention at 1,3,6 and 12 months for the first year, every 6 months for the second year and every year thereafter until the end of the study (median 32.3 months). The treatment outcome based on clinical and radiographic criteria was assessed by calibrated examiners and dichotomized as 'healed+healing' or 'not healed'. The age, gender, stage of root development, preoperative signs and symptoms of apical periodontitis and size of periapical lesion were recorded. The cumulative success proportion and mean time were analysed with the Kaplan-Meier test. The generalized logrank statistic was used to describe prognostic clinical variables. Fisher's exact test was applied for the evaluation of the healing rates. RESULTS: Thirty-nine of the 45 teeth treated with MTA were available for recall. Of these, 29 teeth (74%) revealed calcific apical barrier formation with complete resolution of periapical lesions, 7 teeth (18%) were healing, and 3 teeth (8%) had persistent disease. Thirty-four of the 45 teeth in the CH group were available for recall. Of these, 27 teeth (79%) had complete healing of periapical lesions and had calcific barrier formation, 4 teeth (12%) were healing, and the remaining 3 teeth (9%) had not healed. The survival rate of teeth treated with MTA was similar to the survival rates observed in teeth treated with CH (90% and 91%, respectively, P > 0.05). The generalized logrank statistic revealed that the cumulative success rate of both materials was not significantly different (P > 0.05). None of the tested predictors had an influence on the treatment outcomes of teeth in both groups (P > 0.05). CONCLUSIONS: Apexification with both MTA and CH was associated with similar treatment outcomes. MTA may be proposed as a material for apexification treatment in immature teeth of adult patients due to the shorter treatment time associated with its use.

Effect of apexification on occlusal resistance of immature teeth.

BACKGROUND: Strain distribution was investigated to assess the occlusal resistance alterations in immature teeth under different occlusal force. METHODS: In vitro apexification models of teeth with a funnel-shaped immature apex were obturated with mineral trioxide aggregate (MTA; ProRoot MTA) using different combinations of core materials (10/group): group 1, full-length orthograde obturation of MTA; group 2, a 5-mm MTA apical plug with a composite core; group 3, a 5-mm MTA apical plug and back-filling with warm gutta-percha. Teeth with calcium hydroxide (CH)-medicated canals and untreated teeth with normal apices were tested as controls. The teeth were arranged between two adjacent normal-apex teeth, embedded in a resin mold with a simulated periodontal ligament space. Strain data were recorded from the 3-unit teeth assembly under static compressive occlusal forces (50, 100, 200, and 300 N). Measurements were repeated 20 times for each condition, and the data were statistically analyzed. RESULTS: The immature teeth showed altered occlusal force resistance, placing increased strain on adjacent teeth. Teeth with CH-medicated canals showed significantly inferior occlusal resistance under all tested forces (P < 0.05). Application of an MTA plug with deep composite resin core resulted in significantly better stress-bearing capacity especially under forces of 50 and 300 N (P < 0.05). CONCLUSIONS: The pattern of occlusal force distribution in immature teeth differed according to the canal obturation materials used for apexification. Immature teeth with an MTA apical plug showed more favorable occlusal force resistance than those with CH-medicated canals.

Consequences of tooth luxation associated with complicated crown fracture: a case report.

The objective of this clinical case report is to describe the late treatment performed in a 10-year-old patient who suffered a complicated crown fracture associated with luxation of the maxillary left central incisor. The patient-s parents reported that the patient fell and was immediately taken to a hospital, where radiographs, splinting, and suturing were performed and an anti-inflammatory prescription was provided, but no treatment was given for the exposed pulp. The parents and patient sought treatment at a pediatric dentistry clinic 16 days post-trauma. The clinical examination revealed the presence of a left central incisor with a fracture of enamel and dentin involving the pulp, which was necrotic, and a splint extending from the right lateral incisor to the left lateral incisor. However, it was not possible to diagnose the type of luxation that had occurred. The fractured incisor was treated with periodic changes of calcium hydroxide dressing for apexification for 10 months, and the root was subsequently obturated with gutta percha and root canal sealer. The tooth fragment was stored in physiologic solution during this time. After obturation, tooth darkening was observed, and LED-assisted tooth bleaching was accomplished prior to reattachment of the fractured fragment. The tooth was reexamined every 6 months. Two years after the traumatic event, the left central incisor was infraoccluded in relation to the right central incisor. A radiograph confirmed ankylosis of the traumatized tooth. When trauma affects the enamel, dentin, pulp, and supporting tissues, the prognosis can be unfavorable even when late treatment is adequate, especially when a tooth in a growing patient has points of ankylosis.

Enhanced regeneration potential of mobilized dental pulp stem cells from immature teeth.

OBJECTIVES: We have previously demonstrated that dental pulp stem cells (DPSCs) isolated from mature teeth by granulocyte colony-stimulating factor (G-CSF)-induced mobilization method can enhance angiogenesis/vasculogenesis and improve pulp regeneration when compared with colony-derived DPSCs. However, the efficacy of this method in immature teeth with root-formative stage has never been investigated. Therefore, the aim of this study was to examine the stemness, biological characteristics, and regeneration potential in mobilized DPSCs compared with colony-derived DPSCs from immature teeth. MATERIALS AND METHODS: Mobilized DPSCs isolated from immature teeth were compared to colony-derived DPSCs using methods including flow cytometry, migration assays, mRNA expression of angiogenic/neurotrophic factor, and induced differentiation assays. They were also compared in trophic effects of the secretome. Regeneration potential was further compared in an ectopic tooth transplantation model. RESULTS: Mobilized DPSCs had higher migration ability and expressed more angiogenic/neurotrophic factors than DPSCs. The mobilized DPSC secretome produced a higher stimulatory effect on migration, immunomodulation, anti-apoptosis, endothelial differentiation, and neurite extension. In addition, vascularization and pulp regeneration potential were higher in mobilized DPSCs than in DPSCs. CONCLUSIONS: G-CSF-induced mobilization method enhances regeneration potential of colony-derived DPSCs from immature teeth.

Revascularization of an immature tooth with apical periodontitis using a single visit protocol: a case report.

AIM: To discuss the clinical and radiological outcome of a revascularization procedure which was completed in a single visit (using sodium hypochlorite 5% as the sole disinfectant) in an immature tooth with a necrotic pulp and apical periodontitis. SUMMARY: A 7-year-old girl was referred in pain following trauma to the maxillary anterior region some 6-7 weeks previously. The maxillary left central incisor tooth was diagnosed with a necrotic pulp and acute apical periodontitis. Under local anaesthesia and rubber dam isolation, an access cavity was prepared. The canal was irrigated with a 5% sodium hypochlorite solution and agitated with an ultrasonic file. A 17% EDTA solution was also used for a final rinse. Bleeding was induced into the canal space from the periapical tissues using a K-file. An MTA layer/barrier was placed directly onto the blood clot, and a further layer of GC Fuji IX cement was placed on top of the MTA to restore the access cavity. The tooth was reevaluated at 6 weeks, 3 months, 6 months, 1 year and 18 months. The tooth has remained symptom free. Radiographic examination shows progressive thickening of the root canal walls, root lengthening and apical closure. KEY LEARNING POINTS: Disinfection with 5% sodium hypochlorite followed by the induction of a blood clot into the root canal space may be sufficient to promote revascularization in certain circumstances. A single visit revascularization procedure is a potential treatment option.

Revascularization of immature permanent teeth with apical periodontitis.

The aim of this minireview was to identify and review the scientific evidence regarding regenerative endodontic protocols claiming to revascularize permanent immature teeth with apical periodontitis. The literature was identified using the PubMed/MEDLINE, Scopus, Scirus, EMBASE and Cochrane databases up to February 2013. Studies were selected independently by two different researchers (kappa index: 0.88), based on established inclusion/exclusion criteria. The methodological quality of the reviewed papers was classified as high, medium or low (HQ, MQ, LQ). The search strategy identified 285 titles. Nine studies, both human and animal based, were selected after application of the criteria (LQ:5; MQ:4). In most of these studies (seven of nine), the revascularization protocol included a triple antibiotic combination as canal disinfectant for a period of 1-4 weeks after blood clot formation (LQ:5; MQ:4), although there is no clear consensus about the treatment protocol. Two studies reported tooth discoloration after the revascularization process (LQ:2), and only three (LQ:1; MQ:2) reported a success rate of 54.9% in dogs and 73.6% and 80% in humans, respectively. Revascularization of immature permanent teeth with apical periodontitis is possible and preferable to apexification. Nevertheless, there is a widespread lack of randomized clinical trials and blinded measures. In addition, the small sample sizes that are common in these studies as well as the generally low quality of the analysed publications require the results to be viewed with caution. There is a high risk of bias, with a low quality of available information, for developing clinical guidelines for regenerative endodontic protocols; rigorous randomized clinical trials are therefore needed.

Characterization of cells in blood evoked from periapical tissues in immature teeth with pulp necrosis and their potential for autologous cell therapy in Regenerative Endodontics.

OBJECTIVE: The objectives of this study were to isolate, characterize progenitor cells from blood in the root canals of necrotic immature permanent teeth evoked from periapical tissues and evaluate the applicable potential of these isolated cells in Regenerative Endodontics. DESIGN: Ten necrotic immature permanent teeth from seven patients were included. Evoked bleeding from periapical tissues was induced after chemical instrumentation of the root canals. Cells were isolated from the canal blood and evaluated for cell surface marker expression, multilineage differentiation potential, proliferation ability, and target protein expression. Cell sheets formed from these cells were transferred into human root segments, and then transplanted into nude mice. Histological examination was performed after eight weeks. Data analysis was conducted using one-way ANOVA followed by Tukey's post-hoc comparison, considering p < 0.05 as statistically significant. RESULTS: The isolated cells exhibited characteristics typical of fibroblastic cells with colony-forming efficiency, and displayed Ki67 positivity and robust proliferation. Flow cytometry data demonstrated that at passage 3, these cells were positive for CD73, CD90, CD105, CD146, and negative for CD34 and CD45. Vimentin expression indicated a mesenchymal origin. Under differentiation media specific differentiation media, the cells demonstrated osteogenic, adipogenic, and chondrogenic differentiation potential. Subcutaneous root canals with cell sheets of isolated cells in nude mice showed the formation of pulp-like tissues. CONCLUSIONS: This study confirmed the presence of progenitor cells in root canals following evoked bleeding from periapical tissues of necrotic immature teeth. Isolated cells exhibited similar immunophenotype and regenerative potential with dental mesenchymal stromal cells in regenerative endodontic therapy.

Revascularization of an immature tooth with a necrotic pulp using platelet-rich fibrin: a case report.

AIM: To discuss the clinical and radiological outcome of a revascularization procedure in an immature tooth with a necrotic pulp using platelet-rich fibrin (PRF), a second-generation platelet concentrate. SUMMARY: A 7-year-old male reported with pain in the maxillary anterior region as a result of the injury to his immature right maxillary central incisor tooth. After preparation of the access cavity, the necrotic pulp was removed and the canal irrigated using 5.25% sodium hypochlorite solution. The canal was then dried and packed with triantibiotic paste for 3 weeks. After removal of the antibiotic paste, a 5 mL sample of whole venous blood was drawn from the patient's forearm to prepare PRF. The freshly prepared PRF was condensed in the canal until the cementoenamel junction. Three millimetres of white MTA was placed directly over the PRF clot. Three days later, the tooth was restored using a permanent restoration. At 7-, 12- and 15-month recall, the tooth was asymptomatic with no sensitivity to percussion or palpation. At 12- and 15-month follow-up, the tooth responded positively to cold and an electric pulp test, and similarly to adjacent lateral incisor and canine teeth. Radiographic examination demonstrated continued thickening of root canal walls, root lengthening and apical closure. KEY LEARNING POINT: 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, and acts as a matrix for tissue ingrowth.

Histologic and radiological observations of a human immature premolar with pulp necrosis treated with regenerative endodontic procedure - A case report of a four-year follow-up.

Background: Reports are found on long-term radiographic follow-up of teeth treated with regenerative endodontic techniques, but scarce literature is observed regarding the tissue formed in the root canal. A four-year radiographic follow-up with histologic findings in an immature mandibular premolar with dens evaginatus that underwent a regenerative endodontic procedure (REP) is presented here. After four years following REP, the tooth was extracted for orthodontic purposes thereby presenting an opportunity to report the histologic findings. Summary: The radiographic changes included a slight root lengthening and thickening and apex closure. Histologic evaluation revealed a fibrous connective tissue with an inflammatory infiltrate in the canal space. In the apical region, cementum-like irregular mineralization developed toward the center, giving the appearance of a closed apex. Root thickening, increase in length, and radiographic closure of the apex occurred due to cemental hyperplasia. Conclusion: After 4 years following REP in an immature mandibular premolar with apical periodontitis, granulation tissue had formed in the root canal, indicating repair and not regeneration.

Root Maturation of an Immature Dens Invaginatus Despite Unsuccessful Revitalization Procedure: A Case Report and Recommendations for Educational Purposes.

BACKGROUND: The clinical management of teeth with complex dens invaginatus (DI) malformations and apical periodontitis may be challenging due to the lack of routine. The aim of this case report is to describe the endodontic treatment of an immature tooth with DI and to discuss strategies for preclinical training for teeth with such malformations. CASE REPORT: A 9-year-old male presented with an immature maxillary incisor with DI (Oehlers Type II) and apical periodontitis which was diagnosed by cone beam computed tomography (CBCT). Revitalization was initially attempted but then abandoned after failure to generate a stable blood clot. Nevertheless, considerable increase in both root length and thickness could be detected after medication with calcium hydroxide followed by root canal filling with MTA as an apical plug. CONCLUSIONS: The endodontic management of teeth with DI requires thorough treatment planning. In immature teeth, under certain conditions, root maturation may occur even with conventional apexification procedures. From an educational perspective, different strategies including CBCT and 3D-printed transparent tooth models for visualization of the complex internal morphology and redesigned 3D-printed replica with various degrees of difficulty for endodontic training, can be used to overcome the challenges associated with endodontic treatment of such teeth.

The Effect of General Anesthesia on the Outcome of Root Canal Treatment in Pediatric Patients-A Retrospective Cohort Study.

This study aimed to evaluate the effect of general anesthesia (GA) on the 1-year outcome of Root Canal Treatment (RCT) performed in pediatric patients and to compare it to the outcome of RCT in pediatric patients without GA. Patients admitted for RCT in permanent dentition in a public hospital, dated 2015 to 2020, age 8-15 with a minimum of one year follow-up period, were included in the study. The sample consisted of 326 teeth from 269 patients treated by a single operator, with a recall rate of 81%. Overall, 124 teeth were treated under GA and 142 teeth were without GA. The mean follow-up time was 31.5 months. Data underwent statistical analysis and the significance threshold was set for p < 0.05. Of the total cases, 90% showed favorable outcomes. A significantly higher favorable outcome was seen in the GA group than in the non-GA group (98% and 85%, respectively, p < 0.001). The outcome was significantly affected by the type and quality of the coronal restoration, degree of root development, and lesion size (p < 0.05). According to the current study, in uncooperative pediatric patients, a more favorable outcome of root canal treatment can be obtained under GA than LA if the procedure is carried out with immediate restoration.

Different endodontic treatments induced root development of two nonvital immature teeth in the same patient: A case report.

BACKGROUND: Pulp revascularization is a novel way to treat immature teeth with periapical disease, and the technique has become increasingly well established in recent years. By puncturing the periapical tissue, bleeding is induced, and a blood clot is formed in the root canal. The blood clot acts as a natural bioscaffold onto which mesenchymal stem cells from periapical tissue can be seeded and restore pulp vascularity, thus promoting root development as well as apical closure. Although the effect of pulp revascularization is ideal, there are certain requirements for the apical condition of the teeth. The apical barrier technique and apexification are still indispensable for teeth that cannot achieve ideal blood clot formation. In addition, a meta-analysis of several clinical studies concluded that pulp revascularization has no significant advantages over other treatments. CASE SUMMARY: A 10-year-old girl complained of pain in the right upper and lower posterior teeth for 2 d. Clinical and radiological examinations revealed that both the right maxillary and mandibular second premolars were immature with periapical radiolucency. The right maxillary second premolar was treated by pulp revascularization, while the right mandibular second premolar was treated by conventional apical barrier surgery after revascularization failed. The purpose of this report is to compare the different root maturation processes induced by the pulp revascularization and apical barrier techniques in the same patient in homonymous teeth from different jaws. Twelve months of follow-up showed that the apical foramen of both teeth presented a clear tendency to close; however, the tooth treated with pulp revascularization showed a significant increase in root length as well as root canal wall thickness. CONCLUSION: For the treatment of nonvital immature teeth, pulp revascularization showed a superior therapeutic effect in comparison with the apical barrier technique.

Outcome of Regenerative Endodontic Procedures in Nonvital Immature Permanent Teeth Using 2 Intracanal Medications: A Prospective Randomized Clinical Study.

INTRODUCTION: This randomized clinical trial aimed to assess and compare the long-term clinical and radiographic outcomes of regenerative endodontic procedures (REPs) in treating nonvital immature permanent teeth using 2 intracanal medicaments. METHODS: Forty-five patients yielding a total of 50 anterior and posterior nonvital immature teeth were randomly divided into 2 groups. REPs using either nonsetting calcium hydroxide (Ca[OH]2) (n = 25) or modified triple antibiotic paste (TAP) (n = 25) as intracanal medicaments were performed. NeoMTA Plus (Avalon Biomed Inc) was applied for coronal sealing. Cases were followed up clinically and radiographically for 36 months. The survival rate, success rate, and clinical outcome measures were analyzed. Preoperative and recall radiographs were evaluated for dimensional changes in root length, dentin thickness, apical diameter, and periapical radiolucency. RESULTS: At the 36-month follow-up, the success and survival rates were 81.6% and 100%, respectively, in which 79.4% of cases showed complete resolution of periapical radiolucency with no significant difference between the nonsetting Ca(OH)2 and modified TAP groups (P > .050). The cumulative changes in root length, root dentin thickness, and apical diameter throughout the study period were observed in 47.9%, 77.1%, and 89.6% of cases, respectively, with no significant differences between groups (P ≥ .39). Intracanal calcifications were detected in 60% of cases with no significant difference between groups (P = .77). CONCLUSIONS: REPs, using either nonsetting Ca(OH)2 or modified TAP as the intracanal medicament, exhibited high success and survival rates over a follow-up period of 36 months with equally favorable clinical and radiographic outcome data.

Success and Complication Rates of Revascularization Procedures for Immature Necrotic Teeth: A Systematic Review.

Frequently, adolescents exhibit instances of immature necrotic teeth, which are identifiable by their slender root walls and unclosed root tips. The lack of a natural narrowing near the root's end creates difficulty when using standard endodontic procedures, making the effective sealing of the immature root canal difficult or impractical. Revascularization therapy surfaces as a prospective strategy for addressing the management of undeveloped, non-vital, immature, necrotic teeth. Notwithstanding this, apexification continues to hold prominence in the preferences of clinicians owing to its perceived predictability in treatment outcomes. A systematic investigation was conducted involving various search engines and databases, covering the period from 2001 to 2023. The main aim of this investigation was to find randomized clinical trials that compared the efficacy of revascularization therapy to apexification for treating immature necrotic teeth. The evaluation included a thorough examination of both clinical and radiographic outcomes assessing the success rates and complications. Out of the 850 identified articles, 15 studies were chosen for comprehensive analysis. Notable dissimilarities were not identified between the revascularization therapy and apexification groups concerning parameters such as rates of periapical healing, overall effectiveness/invalidation, and apical closure. However, concentrating on measurable factors, it became clear that the revascularization treatment group displayed a notable rise in root length compared to the apexification group. Both revascularization endodontic therapy and apexification demonstrated effectiveness in addressing periapical periodontitis healing and open apex closure. Pulp revascularization stood out for its notable efficacy in enhancing root elongation and thickening, all while having a reduced likelihood of treatment being deemed ineffective overall.

"Meta-analysis of regenerative endodontics outcomes with antibiotics pastes and calcium hydroxide. The apex of the iceberg".

PORPOSE: The aim of this study was to evaluate, through a meta-analysis, the predictability of Regenerative Endodontic therapies with antibiotic pastes and calcium hydroxide [Ca(OH)2], related to four variables as follows: root dentin wall thickening, apical closure, apical repair and root lengthening. METHODS: Literature electronic searches were performed in Pubmed - MEDLINE, Scopus and Lilacs-BVS platforms using appropriate search terms, Mesh (Medical Subject Headings), DeCS (Health Sciences Descriptors) and Boolean operators comprising articles published between 2009 and 2020. Thirty-two original indexed papers were included making a total of 758 regenerative endodontic procedures. A descriptive meta-analysis was performed. RESULTS: Dentin wall thickening was present in 66% (CI95: 58%-73%) of the cases treated with antibiotic paste, while when Ca(OH)2 was used, a percentage of 53% (CI95: 26%-78%), was obtained. When antibiotic paste was used, apical closure was found in the 66% (CI95: 58%-73%) of the regenerative endodontic procedures, while when Ca(OH)2 was used, 88% (CI95: 80%-93%) of the cases were found to reach apical closure. Root lengthening and apical repair were found satisfactory for both disinfection protocols. CONCLUSIONS: There could be differences between the two treatments since a higher percentage of root dentin wall thickening was found when using antibiotic pastes, while a higher percentage of apical closure was found when calcium hydroxide was used. Development of more clinical studies would be necessary in order to confirm the observed differences. The proposed approach could provide a useful contribution for endodontists when planning regenerative endodontic procedures, so as to guide decision-making to the best elective treatment and to select the appropriate disinfection method in accordance with preoperative radiographic diagnosis of root development stage, then increasing the predictability of regenerative endodontic treatment and reducing potential risk of root fractures.