Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification.

AIM: This report addresses the management of a large persistent discharging lesion in an 11-year-old boy. The report describes the use of aspiration-irrigation technique for the management of immature necrotic tooth with persistent discharge after a failed regenerative procedure. BACKGROUND: Regenerative endodontics aim to provide an increase in root canal width, length, and in apical closure. Alternative procedures, such as apexification, should be attempted when regeneration fails. If the canal cannot be dried to persistent discharge, the aspiration-irrigation technique can be used. The technique relies on using aspiration along with irrigation to remove pus from the periapical area. CASE DESCRIPTION: This is a case for an 11-year-old patient who had trauma to tooth #11, which resulted in the complicated crown fracture. He had an emergency management that included pulpectomy and intracanal medication at another clinic. Two years later, the patient was presented to our clinic. Upon examination, the diagnosis was previously initiated therapy with asymptomatic apical periodontitis in immature tooth #11. Regeneration was attempted first but failed. The mineral trioxide aggregate (MTA) plug was removed, and the canal had persistent pus discharge. The canal was filled with intracanal medication, and then 2 weeks later, the canal was filled with triple antibiotic paste (TAP). Next visit, and due to continuous discharge, tooth #11 was treated conservatively with an intracanal aspiration-irrigation technique. An IrriFlex needle attached to a high-volume suction was used to aspirate the cystic fluid. Mineral trioxide aggregate plug apexification was performed in a later visit and the tooth was restored. CONCLUSION: During the 3-month and 16-month follow-up, there was resolution of the symptoms, a decrease in the periapical lesion size, and soft tissues appeared within normal limits. CLINICAL SIGNIFICANCE: Regenerative procedures are a good option for immature necrotic teeth. These procedures may fail due to persistent pus discharge from the root canals. The aspiration-irrigation technique is a good treatment option in cases of consciously discharging canals. How to cite this article: Alsofi L, Almarzouki S. Failed Regenerative Endodontic Case Treated by Modified Aspiration-irrigation Technique and Apexification. J Contemp Dent Pract 2024;25(1):92-97.

Damaged first permanent molar: how conservative can we be? / Première molaire permanente délabrée : jusqu'où peut-on être conservateur ?

Introduction: It is a fact reported in the literature that the first permanent molar is the most frequently decayed tooth. Our treatment choice is based mainly on two clinical criteria: the degree of coronal decay and the damage to the pulp tissue. In the absence of pulp tissue necrosis, the following therapeutic gradient: indirect pulp capping, direct pulp capping, partial pulpotomy, cameral pulpotomy should be implemented with the objective of maintaining pulp vitality regardless the degree of maturity of the molar. Discussion: In the case of pulp tissue necrosis, if the tooth is immature, stopping root construction and apical closure requires an apexification or endodontic regeneration technique. The prognosis of these necrotic teeth remains uncertain in the medium and long term (risk of fractures). This raises the question of the indication for avulsion of the first permanent molar (FPM). Objectives: The main objectives of this article are to present the means of conservation and their limits. Conclusion: The decision to retain a FPM is based on several criteria, including assessment of pulpal status (which remains problematic, especially on immature permanent teeth) and the feasibility of coronal restoration. The decision to retain or extract a FPM must be the subject of a multidisciplinary discussion between a paediatric dental surgeon and a specialist qualified in dentofacial orthopaedics.

Introduction: C'est un fait rapporté dans la littérature : la première molaire permanente est la dent la plus fréquemment délabrée. Notre choix thérapeutique repose principalement sur deux critères cliniques : le degré de délabrement coronaire et l'atteinte du tissu pulpaire. En l'absence de nécrose du tissu pulpaire, le gradient thérapeutique suivant : coiffage pulpaire indirect, coiffage pulpaire direct, pulpotomie partielle, pulpotomie camérale doit être mis en œuvre avec pour objectif de maintenir la vitalité pulpaire quel que soit le degré de maturité de la molaire. Discussion: En cas de nécrose du tissu pulpaire, si la dent est immature, l'arrêt de l'édification radiculaire et de la fermeture apicale requiert une technique d'apexification ou de régénération endodontique. Or le pronostic de ces dents nécrosées reste incertain à moyen et long termes (risque de fractures). Se pose alors la question de l'indication d'avulsion de la première molaire permanente (PMP). Objectifs: Les principaux objectifs de cet article sont de présenter les moyens de conservation et leurs limites. Conclusion: La décision de conservation d'une PMP repose sur plusieurs critères dont l'évaluation du statut pulpaire (qui reste problématique, surtout sur dent permanente immature) et la faisabilité de la restauration coronaire. La décision de conserver ou d'extraire une PMP doit faire l'objet d'une discussion pluridisciplinaire entre chirurgien-dentiste pédiatrique et spécialiste qualifié en orthopédie dento-faciale.

Apexification Outcomes in the United States: A Retrospective Cohort Study.

INTRODUCTION: This epidemiological analysis used procedure codes from dental insurance claims data to identify apexification cases and evaluate survival at the tooth-level. METHODS: Dental insurance claims data from New York State (2006-2019) and Massachusetts (2013-2018) were used in an observational, retrospective cohort study to evaluate the provision and treatment outcomes of apexification. Statistical analyses included Kaplan-Meier survival estimates and Cox proportional hazards regression. Cox proportional hazard regression was used to evaluate the hazard of adverse event occurrence by age, gender, tooth type, placement of permanent restoration, and dental provider type. A sensitivity analysis evaluated potential bias in the survival estimates and adjusted hazard ratios (aHRs) due to differential loss to follow-up. Robust standard errors were used to account for potential dependence between teeth within an individual. RESULTS: The analytic cohort of 575 individuals included 632 teeth, with an average follow-up time of 64 months. The survival rates of apexification procedures were 95% at 1 year; 93% at 2 years; 90% at 3 years; and 86% at 5 years. Tooth retention following apexification was 98% at 1 year; 96% at 2 years; 95% at 3 years; and 90% at 5 years. Tooth type and subsequent placement of a permanent restoration were significant predictors of survival after apexification. CONCLUSIONS: The procedural and tooth survival outcomes of apexification were high and comparable to studies that analyzed clinical data on tooth survival following apexification.

Comparison of fracture resistance of simulated immature teeth using four different commercially available apexification materials - An in vitro study.

Introduction: The aim of this study was to compare the fracture resistance of simulated immature teeth using four different apical plug materials, i.e. Pro- Root MTA, Neo- MTA Plus, Biodentine, and Bioactive Glass. Materials and Methods: 80 extracted human maxillary anterior teeth were divided into 4 groups for this study. They were prepared using Peeso reamers to simulate immature teeth and to mimic Cvek's stage 3 of root development. A 5 mm apical barrier was placed using different materials. The remaining canal was obturated using gutta-percha and AH plus sealer. The final samples were stored at 37°C and 100% humidity for 4 weeks. Fracture resistance of the teeth was measured in Newtons using a universal testing machine. The comparison of fracture resistance between the four groups was done using Kruskal Walis ANOVA followed by post hoc Mann Whitney U test for pairwise comparison. Results: Biodentine group showed the highest fracture resistance as compared to the other three groups and the difference was highly significant (P < 0.001). Conclusions: Biodentine can be advocated over MTA as an effective material for the management of teeth with wide open apex. Bioactive glass also has shown promising results in increasing the fracture resistance of simulated immature teeth.

Comparison of three different biomaterials used in in vitro molar apexification models.

OBJECTIVES: New biomaterials had some advantages such as mixing and easier application as compared to traditional MTA in single step apexification method. This study aimed to compare the three biomaterials used in the apexification treatment of immature molar teeth in terms of the time spent, the quality of the canal filling and the number of x-rays taken to complete the process. METHODS: The root canals of the extracted thirty molar teeth were shaped with rotary tools. To obtain the apexification model, ProTaper F3 was used retrograde. The teeth were randomly assigned into three groups based on the material used to seal the apex; Group 1: Pro Root MTA, Group 2: MTA Flow, Group 3: Biodentine. The amounts of the filling, the number of radiographs taken until treatment completion and the treatment duration were recorded. Then teeth were fixed for micro computed tomography imaging for quality evaluation of canal filling. RESULTS: Biodentine was superior to the other filling materials according to time. MTA Flow provided greater filling volume than the other filling materials in the rank comparison for the mesiobuccal canals. MTA Flow had greater filling volume than ProRoot MTA in the palatinal/distal canals(p = 0.039). Biodentine had greater filling volume more than MTA Flow in the mesiolingual/distobuccal canals (p = 0.049). CONCLUSIONS: MTA Flow was found as a suitable biomaterial according to the treatment time and quality of root canal fillings.

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.

Long-term Outcome of Endodontically Treated Traumatized Immature Upper Incisors.

INTRODUCTION: In a growing child, preservation of traumatized immature permanent upper incisors is challenging. This study aimed to evaluate the long-term outcome of endodontically treated traumatized immature upper incisors and associated variables. METHODS: A total of 183 traumatized immature upper incisors treated with pulpotomy, apexification, or regenerative endodontic procedure (REP), with follow-up between 4 and 15 years, were assessed for presence of pulpal responses or periodontal/bone responses using standardized clinical and radiologic criteria. Logistic regression, including stage of root development, type and complexity of traumatic event, type of endodontic intervention, and history of orthodontic management, were used to estimate impact on tooth survival and occurrence of tissue responses. Study approved by Ethics Committee Research UZ/KU Leuven (S60597). RESULTS: After a median follow-up of 7.3 years (interquartile range, 6.1-9.2), 159 teeth (86.9%) were still functional. From these teeth, 58 (36.5%) developed tissue responses. This was significantly associated with stage of root development at moment of trauma (root length <¾) and type of endodontic intervention (REP presenting worst outcome). Tooth loss (24 teeth, 13.1%) occurred after a mean time span of 3.2 years (±1.5) and was significantly associated with type and complexity of the traumatic event and type of endodontic intervention, with apexification showing better results than REP (odds ratio, 0.30; 95% confidence interval, 0.11-0.79). CONCLUSIONS: A large number of endodontically treated traumatized immature teeth could be kept functional. Very immature teeth, teeth with periodontal tissue damage, and teeth treated with REP were at highest risk for an unfavorable outcome.

Treatment outcomes of immature permanent necrotic evaginated teeth: A retrospective study comparing regenerative endodontic procedures with apexification.

BACKGROUND: Few studies have compared the outcomes of regenerative endodontic procedures (REPs) and calcium hydroxide apexification focusing on necrotic teeth with dens evaginatus. AIM: To qualitatively and quantitatively compare the treatment outcomes of REPs and calcium hydroxide apexification in teeth with dens evaginatus. DESIGN: Immature permanent necrotic evaginated teeth treated with REPs or calcium hydroxide apexification for a follow-up period of at least 12 months were included. Tooth success and survival rates were analyzed. Changes in radiographic root length, apical diameter, and radiographic root area (RRA) were quantified. Prognostic factors that might influence RRA were identified via multivariate linear regression analysis. RESULTS: A total of 112 teeth (50 REP cases and 62 apexification cases) with a median follow-up period of 26.5 months were included. Regenerative endodontic procedures and calcium hydroxide apexification exhibited similar satisfactory success and survival rates (p > .05). Additionally, 88 teeth were quantitatively analyzed. The REP group presented a significantly greater percentage increase in RRA and less decrease in apical diameter than the calcium hydroxide apexification group (p < .05). Teeth treated with REPs and with Stages 7 and 8 of root development showed a better gain in RRA (p < .05). CONCLUSION: While REP and calcium hydroxide apexification had similar success and survival rates, teeth with REPs showed an increase in RRA, indicating that REP is the preferred choice.

Tratamento endodôntico em dente permanente traumatizado com rizogênese incompleta: relato de caso / Endodontic treatment in permanent traumatised tooth with incomplete rhizoganis: case report / Tratamiento endodóntico en diente permanente traumatizado con rizoganis incompleta: presentación de un caso

Os traumatismos dentários representam um problema de saúde pública devido à alta prevalência e impacto psicossocial, sendo muito frequentes em crianças podendo resultar em necrose pulpar e culminar na rizogênese incompleta de dentes permanentes. Nestes casos de traumatismos em dentes permanentes com rizogênese incompleta e necrose pulpar, o tratamento mais indicado pela literatura é a apicificação, sendo um tratamento complexo e longo. Considerando a importância deste tema, o objetivo deste trabalho é relatar o caso de um paciente com traumatismo dental e necrose pulpar, que acarretou a interrupção do desenvolvimento completo e adequado do ápice dentário, sendo necessária a intervenção por meio da técnica de apicificação e o acompanhamento a longo prazo. O caso trata-se de uma menina em que um traumatismo dentário acarretou fratura de um incisivo central superior com formação radicular incompleta, comprometendo tanto a estética quanto a vitalidade do dente. Foi realizado o tratamento endodôntico com apicificação e posteriormente ao plug apical de MTA. O dente foi restaurado definitivamente com resina composta e realizado acompanhamento do paciente. Nas consultas de acompanhamento houve ausência de sintomatologia dolorosa e satisfação da paciente com a aparência atual. Sendo assim, a apicificação apresenta-se como uma ótima alternativa para dentes com rizogênese incompleta e necrose pulpar, embora longo houve uma melhora estética e satisfação do paciente.

Dental trauma represents a public health problem due to its high prevalence and psychosocial impact, being very frequent in children and can result in pulp necrosis and culminate in incomplete root formation of permanent teeth. In these cases of trauma to permanent teeth with incomplete root formation and pulp necrosis, the most indicated treatment in the literature is apexification, which is a complex and long treatment. Considering the importance of this topic, the objective of this work is to report the case of a patient with dental trauma and pulp necrosis, which caused the interruption of the complete and adequate development of the dental apex, requiring intervention through the apexification technique and follow-up. long-term. The case is about a girl in which a dental trauma resulted in a fracture of a maxillary central incisor with incomplete root formation, compromising both the esthetics and the vitality of the tooth. Endodontic treatment was performed with apexification and then apical MTA plug. The tooth was definitively restored with composite resin and the patient was followed up. In the follow- up consultations, there was no painful symptomatology and the patient was satisfied with her current appearance. Thus, the apexification presents itself as a great alternative for teeth with incomplete root formation and pulp necrosis, although in the long run there was an aesthetic improvement and patient satisfaction.

Los traumatismos dentales representan un problema de salud pública debido a su alta prevalencia e impacto psicosocial, siendo muy frecuentes en niños y pudiendo dar lugar a necrosis pulpar y culminar en la formación incompleta de la raíz de los dientes permanentes. En estos casos de traumatismos en dientes permanentes con formación radicular incompleta y necrosis pulpar, el tratamiento más indicado en la literatura es la apexificación, que es un tratamiento complejo y largo. Considerando la importancia de este tema, el objetivo de este trabajo es relatar el caso de una paciente con traumatismo dentario y necrosis pulpar, que causó la interrupción del desarrollo completo y adecuado del ápice dentario, requiriendo intervención a través de la técnica de apexificación y seguimiento. a largo plazo. Se trata de una niña en la que un traumatismo dental provocó la fractura de un incisivo central maxilar con formación radicular incompleta, comprometiendo tanto la estética como la vitalidad del diente. Se realizó tratamiento endodóntico con apexificación y posterior taponamiento apical con MTA. El diente fue restaurado definitivamente con resina compuesta y el paciente fue sometido a seguimiento. En las consultas de seguimiento, no había sintomatología dolorosa y la paciente estaba satisfecha con su aspecto actual. Así, la apexificación se presenta como una gran alternativa para dientes con formación radicular incompleta y necrosis pulpar, aunque a la larga se produjo una mejoría estética y satisfacción de la paciente.

Regenerative Endodontics by Cell Homing: A Review of Recent Clinical trials.

INTRODUCTION: The conventional treatment for irreversibly inflamed or necrotic teeth is root canal treatment or apexification. Regenerative endodontics aims to regenerate the damaged "pulp-like" tissue, which can preserve the teeth' vitality and sensitivity while avoiding necrosis. The main clinical benefit is root maturation. The "pulp-like" tissue does not refer to regenerated pulp tissue with an odontoblastic layer or the formation of pulp-dentin complexes. The cell homing technique is built on endogenous stem cells and their capacity to regenerate tissue. Cell homing refers to endogenous cells' migration or infiltration into the cite when stimulated by physiochemical or biological stimuli or by passive flow with a blood clot from the apical tissue. Its Regenerative Endodontic Procedures success criteria are defined by the American Association of Endodontists. The purpose of this article is to provide an overview of vital pulp tissue and various strategies to promote regeneration of damaged pulp tissue. The cell homing technique will be reviewed through clinical trials. METHODS: We performed a comprehensive literature review on a total of nine clinical trials of regenerative endodontics using the cell-homing technique based on three databases and duplicate manuscripts were removed. RESULTS: Regenerative endodontics using the cell-homing technique shows promising results that can be translated into clinical practice. However, a favorable result was observed in immature teeth, and the results are contradictory in mature teeth. CONCLUSION: Regeneration therapy is an attractive new alternative to conventional endodontic treatments. Preservation of vitality and continuation of root development in damaged teeth would be a clear advantage.

Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth.

This review guidance is a work in progress because the limitations of regenerative endodontics are still being discovered. The endodontic treatments for immature permanent teeth with a necrotic pulp can vary considerably among endodontic practitioners. Whereas, regenerative endodontic treatments are growing in popularity and are creating ever more complex treatment protocols, involving revascularization and/or autologous platelet-rich plasma and scaffolds to elicit host stem cell de novo tissue formation to reestablish the vitality of immature teeth for the purpose of continuing root maturation. Despite much evolving controversy about their potential benefits, risks, prognosis, and contraindications, this review is aimed to discuss how to ensure that regenerative endodontic treatments are successful, by strictly adhering to case selection criteria, and following precise steps to accomplish and monitor the success of the treatment. A review of the endodontic literature was performed, together with practical observations of the problems and outcomes of performing regenerative endodontic treatments. Traditionally, apexification has long been the treatment of choice provided to immature teeth with a necrotic pulp. Regenerative endodontics may be provided as an alternative to apexification, if the tooth and patient meet all the case selection criteria, and if there are no contraindications. Regenerative endodontics has the unique potential advantage of being able to continue the root development in immature permanent teeth, thereby potentially saving the teeth for the lifetime of the patient. Whereas, conventional endodontic root canal treatment, Cvek partial pulpotomy, apexogenesis, and apexification, should always be provided when these treatments are more likely to benefit the patient because they can be more successful than regenerative endodontics.

Modified pulpotomy procedure in immature permanent teeth with apical periodontitis: a randomised controlled trial.

OBJECTIVES: The objective of this study was to evaluate the effectiveness of a modified pulpotomy (MP) procedure in immature permanent teeth with apical periodontitis (AP). DESIGN: Randomised controlled trial. SETTING: One public hospital in Shanghai, China PARTICIPANTS: A total of 33 teeth (31 patients) with a definitive diagnosis of AP with radiographic periapical radiolucency were recruited in this study. All the patients (teeth) completed the study accordingly. METHODS AND INTERVENTION: Patients were randomly assigned to either MP or apexification treatment groups and were followed up for 12 months. Clinical symptoms and complications were recorded, and parallel periapical radiographic images were used to measure changes in root length and apical diameter. Wilcoxon's rank sum test and Fisher's exact test were used to compare the clinical and radiographic outcomes between MP and apexification, and analysed with analysis of variance. MAIN OUTCOME MEASURE: The primary outcome was increase in root length at 12 months. The secondary outcomes included tooth survival, clinical success and decrease in apical diameter. RESULTS: MP group showed a significant increase in root length (10.05%±2.14% vs 1.16%±0.79%, p<0.05) at 12 months and a decrease in apical diameter (48.88%±10.42% vs 15.90%±8.88%, p<0.05) as compared with the apexification group. The tooth survival rate was 100%, and 90.91% (30/33) of teeth were asymptomatic with apical healing in both treatment groups (p>0.05). CONCLUSIONS: MP can be an option for treating immature permanent teeth with AP. MP showed better performance in terms of continued root maturation than apexification. MP and apexification achieved comparable outcomes with regard to the resolution of clinical symptoms and apical healing. TRIAL REGISTRATION NUMBER: ChiCTR-INR-17012169.

Neural Regeneration in Regenerative Endodontic Treatment: An Overview and Current Trends.

Pulpal and periapical diseases are the most common dental diseases. The traditional treatment is root canal therapy, which achieves satisfactory therapeutic outcomes-especially for mature permanent teeth. Apexification, pulpotomy, and pulp revascularization are common techniques used for immature permanent teeth to accelerate the development of the root. However, there are obstacles to achieving functional pulp regeneration. Recently, two methods have been proposed based on tissue engineering: stem cell transplantation, and cell homing. One of the goals of functional pulp regeneration is to achieve innervation. Nerves play a vital role in dentin formation, nutrition, sensation, and defense in the pulp. Successful neural regeneration faces tough challenges in both animal studies and clinical trials. Investigation of the regeneration and repair of the nerves in the pulp has become a serious undertaking. In this review, we summarize the current understanding of the key stem cells, signaling molecules, and biomaterials that could promote neural regeneration as part of pulp regeneration. We also discuss the challenges in preclinical or clinical neural regeneration applications to guide deep research in the future.

Revascularização pulpar, uma nova opção na terapêutica endodôntica: revisão da literatura e caso clínico em paciente adulto / Pulpar revascularization, a new option in endodontc therapy: literature review and case report in adult patient

Introdução: A revascularização pulpar é uma terapêutica que visa regenerar parte do complexo dentino pulpar, proporcionando a continuidade do desenvolvimento radicular, sanando a fragilidade e propensão a fratura que a apicificação apresentava. É um tratamento direcionado a dentes diagnosticados com rizogênese incompleta. Entretanto, a possibilidade de realização da técnica em dentes maduros tem sido alvo de pesquisas e estudo. Objetivo: O objetivo deste estudo, é apresentar através da revisão de literatura e caso clínico, os benefícios dos procedimentos endodônticos regenerativos (REPs), em dentes jovens e maduros, em relação à apicificação. Metodologia: O estudo é uma revisão de literatura, desenvolvida através de pesquisa exploratória e realizada uma abordagem qualitativa. Para a coleta de dados, foi aplicada a técnica de análise documental e revisão bibliográfica consultando PUBMED, Scielo, Google Acadêmico e monografias acadêmicas. O caso clínico foi realizado de acordo com o protocolo atualizado pela AAE em 2016. Discussão: A revascularização pulpar tem mostrado ser um tratamento promissor na endodontia, é preconizada a desinfecção e medicação intracanal, já que não pode haver instrumentação mecânica. Os agentes irrigadores devem ser bactericidas, bacteriostáticos e devem ter baixo teor de toxicidade, já a medicação intracanal deve ter papel inibidor em bactérias gram positivas e gram negativas. Conclusão: A apicificação mesmo com o uso de MTA, que não exige trocas excessivas de medicações, não sana as necessidades que um dente com rizogênese incompleta requer. Sendo assim, a revascularização foi eleita o tratamento de melhor prognóstico para dentes jovens e necrosados. O caso clínico demonstrou qualidade moderada, no tratamento regenerativo em um dente maduro com reabsorção externa, abrindo novas perspectivas para os (REPs)(AU)

Introduction: Pulp revascularization is a therapy that aims to regenerate part of the pulp dentin complex, providing continuity of root development, remedying the fragility and propensity to fracture that apexification presented. It is a treatment aimed at teeth diagnosed with incomplete rhizogenesis. However, the possibility of performing the technique on mature teeth has been the subject of research and study. Objective: The aim of this study is to present, through literature review and clinical case, the benefits of regenerative endodontic procedures (REPs), in young and mature teeth, in relation to apexification. Methodology: The study is a literature review, developed through exploratory research and carried out a qualitative approach. For data collection, the technique of document analysis and bibliographic review was applied, consulting PUBMED, Scielo, Academic Google and academic monographs. The clinical case was performed according to the protocol updated by the SEA in 2016. Discussion: Pulp revascularization has shown to be a promising treatment in endodontics, intracanal disinfection and medication is recommended, as there can be no mechanical instrumentation. Irrigating agents must be bactericidal, bacteriostatic and must have a low level of toxicity, whereas intracanal medication must have an inhibiting role in gram positive and gram negative bacteria. Conclusion: Apexification, even with the use of MTA, which does not require excessive medication changes, does not meet the needs that a tooth with incomplete rhizogenesis requires. Therefore, revascularization was chosen as the treatment with the best prognosis for young and necrotic teeth. The clinical case demonstrated moderate quality in regenerative treatment in a mature tooth with external resorption, opening new perspectives for (REPs)(AU)

[Comparative study on the effect of microscopic revascularization and apexification in the treatment of pulp necrosis of permanent teeth].

PURPOSE: To compare the curative effect of microscopic revascularization and apexification in the treatment of pulp necrosis of permanent teeth. METHODS: Seventy-five cases of pulp necrosis in young permanent teeth were divided into two groups according to different treatment methods. Group A (n=30) underwent revascularization under microscope, while group B (n=45) underwent apexification. The treatment effect and pain improvement of the two groups were compared. The changes of the wall thickness and root canal length of the affected teeth before and after treatment were observed, and the bone-like deposition rate after treatment was recorded. SPSS 23.0 software package was used for statistical analysis. RESULTS: There was no significant difference in the length of root canal between the two groups before treatment (P＞0.05); there was no significant difference in the length of root canal in group B before and after treatment (P＞0.05); the length of root canal in group A was significantly longer than that in group B 6 months after treatment(P＜0.05). There was no significant change in the thickness of root canal wall in group B before and after treatment (P＞0.05). The thickness of root canal in group A was significantly higher than that in group A 6 months after treatment (P＜0.05). Bone-like deposition rate of group A was significantly higher than that of group B 1 month and 6 months after treatment (P＜0.05). The total effective rate of group A and B was 90.00% and 84.44%, the difference was not statistically significant (P＞0.05). The cure rate of group A was 70.00%, which was significantly higher than that of group B (48.89%, P＜0.05). COCLUSIONS: Microscopic revascularization for pulp necrosis of young permanent teeth can effectively promote root development, lengthen root canal and increase the thickness of canal wall, which is better than apexification.

Protección pulpar directa y posterior apexogénesis: informe de un caso clínico / Direct pulp capping followed by apexogenesis: a clinical case report

Objetivo: Describir el tratamiento de un paciente que pre- sentó un incisivo superior permanente con exposición pulpar y desarrollo radicular incompleto utilizando Biodentine como material para la protección pulpar directa. Caso clínico: Un paciente de 9 años fue derivado para la evaluación y el tratamiento del diente 11. El examen clínico y radiográfico reveló la presencia de una fractura amelodentinaria, con exposición pulpar y desarrollo radicular incompleto. Luego de lavar y desinfectar el área de la fractura, se protegió la pulpa expuesta con Biodentine y se restauró la cavidad. El paciente fue citado para control a los 18 y 25 meses. En los controles se comprobó que el diente se mantuvo asintomático y funcional. Luego de 25 meses, el examen clínico y radiográfico confirmó la presencia de pulpa vital y el completo desarrollo del remanente radicular. Los resultados obtenidos en el presente caso clínico sugieren que el empleo de Biodentine puede ser considerado como una valiosa alternativa para la protección de la pulpa ex- puesta en dientes con desarrollo radicular incompleto (AU)

Aim: To describe the treatment of a patient that presented a permanent maxillary central incisor with pulp exposure and incomplete root formation, using Biodoentine as the material for direct pulp protection. Clinical case A 9-year-old male patient was referred for evaluation and treatment of tooth 11. The clinical and radio-graphic examination revealed the presence of a dentinoe- namel fracture, with pulp exposure and incomplete root for- mation. After cleaning and disinfecting the area, the exposed pulp was protected with Biodentine and the cavity was re- stored. The patient was scheduled for control after 18 and 25 months. In these evaluations, it was confirmed that the tooth remained asymptomatic and functional. After 25 months, the clinical and radiographic examination showed the presence of vital pulp and a completed development of the root. The obtained results of this clinical case suggest that Biodentine can be considered a valuable alternative for pulp capping in teeth with incomplete root formation (AU)

Long-Term Outcome of Nonvital Immature Permanent Teeth Treated With Apexification and Corono-Radicular Adhesive Restoration: A Case Series.

INTRODUCTION: This study aimed to evaluate the long-term outcome of 16 permanent maxillary central incisors with nonvital pulps and open apices treated with apexification and corono-radicular adhesive restorations, within a follow-up span of 5 to 22 years. METHODS: Fourteen patients providing a total of 16 teeth treated with mineral trioxide aggregate (n = 12), Biodentine (n = 3), or ß-tricalcium phosphate (n = 1) apical barrier and corono-radicular restoration, with or without fiberglass post, were included. Clinical and radiographic criteria were defined for assessment at recall. Restoration and periapical tissue status evaluation were performed according to FDI World Dental Federation's esthetic, functional, and biological criteria and Ørstavik Periapical Index (PAI). Outcome was dichotomized as "healed" (PAI ≤ 2, asymptomatic with absence of signs of infection) or "not healed" (PAI ≥ 3, presence of clinical signs and/or symptoms). RESULTS: Fourteen of 24 patients were available for the present study (recall rate = 58%). Within a follow-up of 5 to 22 years, 10 (62.5%) teeth were considered "healed," fulfilling both strict clinical and radiographic success criteria. Only 1 tooth was missing due to root resorption and 1 patient was presenting with clinical signs and symptoms at recall, resulting in a survival rate of 93.8%. CONCLUSIONS: Adhesive corono-radicular restoration in nonvital permanent immature teeth treated with apexification allows for favorable long-term outcomes, by ensuring structural reinforcement and coronal microleakage prevention. Teeth sustaining a substantial loss of coronal structure may require post/core placement. In the case of failure, this endodontic-restorative combination ensured teeth survival until growth phase conclusion, thus allowing for proper prosthetic rehabilitation approaches.

Failure of Regenerative Endodontic Procedures: Case Analysis and Subsequent Treatment Options.

INTRODUCTION: Regenerative endodontic procedures (REPs) are considered effective treatments for immature necrotic permanent teeth, with favorable outcomes. However, failed cases require subsequent treatment. This study aimed to review and analyze failed cases after REPs and suggest a treatment algorithm to aid clinical decision-making. METHODS: A total of 111 REP cases were selected that were conducted between 2015 and 2020. Clinical outcomes were assessed based on clinical and radiographic evaluations. The criteria for failure included persistence of clinical signs or symptoms and/or periapical radiolucency showing persistent apical periodontitis. Cases requiring any treatment intervention, including extraction, were also considered failures. RESULTS: Sixteen cases were included as failures. The etiology of pulpal disease was stratified into dental trauma (56%), dens evaginatus (25%), and dental caries (12.5%), with the remaining one case having an undocumented cause. The primary reasons for treatment failure were persistent infection (81.3%) and root resorption (18.7%). The identification time of failure varied, with 6 cases (37.5%) detected in less than 6 months and 10 cases (62.5%) later than 6 months after REPs. Sixteen failed cases received 5 different interventions: second REPs, apexification, conventional root canal treatment, surgical approach, and extraction. CONCLUSIONS: Interventions for failed REPs are challenging. Consideration of the treatability of the tooth, accessibility to the canal, and the presence of an apical seat might be key factors in clinical decision-making to obtain a successful outcome.

Evaluation of a Novel Tool for Apical Plug Formation during Apexification of Immature Teeth.

The purpose of this study was to compare the sealing ability and time required for the formation of Biodentine and mineral trioxide aggregation (MTA) apical plugs, using three different delivery methods: an amalgam carrier (AC), the Micro Apical Placement (MAP) System or a novel tool using a modified cannula (MC). Materials and Methods: A total of 60 uniformed molar roots were divided into three main groups, according to the technique of apical plug formation: AC, MAP, and MC. Each group was divided into two subgroups, according to the filling material used: MTA and Biodentine. A timer was used to calculate the required time for apical plug formation. After setting the filling materials, the apical microleakage of the formed plugs was quantified using the dye extraction method and spectrophotometry. The differences between the groups were analyzed using the one-way ANOVA and LSD post hoc tests. The significance level was set at 0.05. Results: No significant differences were reported in the time required to form the apical plugs in all groups (p > 0.05). However, the apical plugs formed by the AC method had significantly higher microleakage than those formed using the MAP and MC methods (p < 0.05). Conclusion: Within the limitations of this study, the sealing ability of the apical plugs formed by the MC method is comparable to the MAP method and better than the AC method.

Radiographic outcomes and prognostic factors in nonvital immature permanent teeth after apexification with modified calcium hydroxide paste: a retrospective study.

OBJECTIVE: To assess the radiographic outcomes and prognostic factors in nonvital immature permanent teeth after apexification with modified calcium hydroxide paste. MATERIALS AND METHODS: Clinical and radiographic data were collected from 115 necrotic immature permanent teeth (71 caused by trauma and 44 caused by dens evaginatus) treated with apexification using a modified calcium hydroxide. Postoperative root morphology and changes in radiographic root area (RRA) on periapical radiographs were determined and statistically evaluated. Regression analysis was performed to identify factors associated with the outcomes of apexification. RESULTS: The average time for a calcified barrier formation was 10.66 ± 6.37 months. The root morphology after apexification with calcium hydroxide + iodoform paste was similar to that previously described after calcium hydroxide apexification. Compared with the trauma cases, the dens evaginatus cases revealed more type I (40.91% vs 16.9%) and less type II morphology (45.45% vs 67.61%). Although the changes in RRA were limited, the dens evaginatus cases showed greater increment of RRA than the trauma cases (4.12% ± 5.58% vs 0.70% ± 5.21%, P < 0.001). A significant association was found between the preoperative stage of root development and postoperative percentage change in RRA (P < 0.001). CONCLUSIONS: Teeth caused by dens evaginatus had better outcomes after apexification than teeth caused by trauma. Early stages of root development were associated with superior radiographic outcomes. CLINICAL RELEVANCE: Apexification provided reliable outcomes in the treatment of immature teeth with pulp necrosis and apical periodontitis, even though the root development is limited. Treatment decision should be made with comprehensive evaluation of prognostic factors.