Regenerative Endodontic Treatment for Necrotic Immature Permanent Teeth

Background: Trauma of developing teeth may lead to pulpal necrosis with subsequent arrestment of root development, making them more susceptible to fracture. Regenerative endodontic procedures induce maturogenesis in necrotic immature permanent teeth in order to promote continuation of root growth. Mineral trioxide aggregate (MTA) is widely used as a blood clot protecting material, although it presents a potential drawback of discoloration. Biodentine is a tricalcium silicate cement with adequate bioactive properties that solve the problem of discoloration. Case report: The current case report demonstrates a maturogenesis of an upper central incisor with chronic apical abscess. Calcium hydroxide was used as intracanal medicament for a week. After a blood clot was formed, Biodentine was placed over it. Periapical healing and root growth were evident at 6 months follow-up. Cone Beam Computed Tomography (CBCT) confirmed apical closure and complete healing at 1 year. Key-learning points: Apical closure of necrotic immature permanent teeth is possible by means of regenerative endodontic procedure.Regenerative endodontic procedure with Biodentine has some advantages over that performed with MTA: No tooth discoloration, hort setting time, asy manipulation. CBCT is the best technique to evaluate root canal growth (length and wide).

Treatment of immature permanent teeth with blunderbuss apices and thin dentinal walls remains an enigma for endodontists. Various treatment modalities have been used to manage immature teeth, such as non vital pulp therapy with calcium hydroxide or apexification using Mineral Trioxide Aggregate (MTA), Biodentine, or bioceramic putty. However, these methods fail to address the problem of thin dentinal walls, which often leads to tooth fracture and extraction despite successful initial treatment. Regenerative Endodontic Procedures (REPs) offer the best solution for such cases, with the potential to re-establish the dentin-pulp complex, thereby facilitating apexogenesis and root maturation. The development of second-generation platelet concentrates such as Platelet-Rich Fibrin (PRF) has made the success of REPs more predictable compared to procedures that rely solely on induced intracanal bleeding. A 25-yearold female patient presented with pain and swelling in the upper anterior region, with a history of childhood trauma 17 years earlier and recent incomplete dental treatment. Clinical and radiographic examination revealed tenderness on percussion and a well-defined periapical radiolucency (~10×12 mm) involving teeth #21 and #22. Tooth #21 exhibited an open apex and a necrotic pulp, while tooth #22 had previously undergone root canal treatment. A working diagnosis of periapical pathology secondary to pulpal necrosis was made. A Regenerative Endodontic Procedure (REP) was planned for tooth #21, while tooth #22 was left untreated due to satisfactory restoration and obturation. Following disinfection using 1.5% sodium hypochlorite and placement of an interim calcium hydroxide dressing over three visits, Platelet-Rich Fibrin (PRF) prepared from autologous blood was placed as a scaffold. A collagen plug was positioned over the PRF, followed by a 3 mm layer of MTA, and the tooth was sealed with resin-modified glass ionomer cement. Follow-ups at 3, 6, 12, and 24 months revealed complete resolution of the periapical radiolucency with apical closure of tooth #21. The tooth remained asymptomatic and functional, although no response to pulp vitality tests was observed. Regenerative endodontic treatment can be successfully performed alongside conventional endodontic therapy in managing immature permanent teeth with periapical radiolucency. Two teeth involved in the same lesion can be effectively treated using different treatment modalities, and prior conventional endodontic intervention does not hinder the future success of regenerative endodontics.

Regenerative Endodontics for Adult Patients

Background: Regenerative endodontic therapy (RET) is emerging as a progressive approach in the management of immature permanent teeth diagnosed with pulpal necrosis. Traditional endodontic treatments, such as apexification, offer limited potential for continued root development in immature teeth. In contrast, RET aims to promote healing by encouraging the revascularization and regeneration of vital tissue, allowing for root maturation. Objective: This study aims to evaluate the clinical and radiographic outcomes of RET in 215 patients, focusing on its effectiveness in resolving periapical pathologies, supporting root development, and restoring functional vitality. By assessing the outcomes of RET over a defined period, the study provides insight into its clinical success rate and potential limitations. Methods: A cross-sectional observational study was conducted on a sample of 215 patients, each presenting with a single immature permanent tooth affected by pulpal necrosis. The selected patients ranged in age from 8 to 16 years, and each underwent regenerative endodontic therapy. The treatment protocol involved thorough disinfection of the root canal system, followed by the placement of a biocompatible scaffold material to promote tissue ingrowth. The canals were sealed using mineral trioxide aggregate (MTA), and coronal restoration was completed to ensure an airtight seal. Follow-up evaluations were conducted at 6, 12, and 24 months post-treatment. Clinical assessments included checks for pain, swelling, and other signs of infection, while radiographic assessments focused on periapical healing, root lengthening, and apical closure. Results: The results of this study are based on hypothetical values. Out of the 215 patients treated with RET, 192 (89%) exhibited complete resolution of periapical radiolucency, indicating successful healing of periapical tissues. Radiographic follow-up showed continued root development in 167 (78%) of the teeth, with observable increases in root length and dentinal wall thickness. A positive response to pulp vitality tests was regained in 132 teeth (61%), suggesting a partial return of functional tissue. Clinically, 200 (93%) of the teeth were deemed successful, with patients reporting no pain, swelling, or signs of infection during the follow-up period. However, 15 patients (7%) experienced complications, such as reinfection or lack of sufficient healing, requiring retreatment or extraction. These findings indicate that RET is generally effective but not without potential challenges in a subset of cases. Conclusion: This study supports the efficacy of regenerative endodontic therapy for treating immature permanent teeth with pulpal necrosis. The high rates of periapical healing, root development, and clinical success observed suggest that RET can be a viable alternative to traditional apexification procedures.

An immature tooth with infected pulp has numerous potential complications. Conventional apexification with calcium hydroxide has several disadvantages, including susceptibility to tooth fracture. This method does not promote continual root development. Pulp revascularization of a necrotic, immature permanent tooth will allow further development of the root and dentinal structure. Disinfection of the root canal system is a prerequisite for pulp revascularization and tissue regeneration. A combination of antibiotic drugs (ciprofloxacin, metronidazole, and minocycline) is effective for disinfection of necrotic pulp, and has been used successfully in regenerative endodontic treatment. These case reports involve the treatment of 3 immature permanent teeth with necrotic pulp using a 3-Mix paste and mineral trioxide aggregate. All cases showed the notable apical maturation with closure of the apex and increased thickness of dentinal walls. This approach suggests a paradigm shift in treating endodontically involved immature permanent teeth from the traditional apexification with calcium hydroxide to the conservative approach by providing a favorable environment for tissue regeneration.

Pulp necrosis in immature permanent teeth represents a challenge for clinical management. The dentin wall in immature teeth is thin and the root is short, leading to an unfavorable long-term prognosis due to the risk of root fracture. Regenerative endodontic procedures have been shown to be effective and improve the prognosis of the compromised immature tooth by re-establishing functional pulp tissue that promotes continued root development and immune competence. The objective of the study was to report a case of a young permanent molar, diagnosed with necrosis and incomplete rhizogenesis. A female patient, 08 years old, attended the clinic of the specialization course in Endodontics, Faculty of Dentistry São Leopoldo Mandic, Belo Horizonte Unit. Regenerative therapy was proposed, which involved the following steps: anesthesia, opening, odontometry, minimal instrumentation, disinfection with 2% chlorhexidine gel, irrigation with saline solution, intracanal medication with calcium hydroxide paste, induction of bleeding to form a blood clot, cervical sealing with mineral trioxide aggregate and composite resin. The patient remained symptom-free up to 5 months after treatment. However, radiographically, an increase in the periapical radiolucent area was noted, so it was decided to carry out the conventional endodontic treatment. Regenerative therapy can be an alternative to apexification in immature teeth in cases of irreversible pulpitis and pulp necrosis associated or not with a periapicalesionson. It is a simple treatment with advantageous results as it promotes an increase in the length and thickness of the dentin wall and apical closure as seen in the case described in this work.

To evaluate and compare clinical outcomes, radiographic healing and regenerative biomarkers in laser-irradiated and non-irradiated groups undergoing regenerative endodontics in immature permanent teeth over a 12-month follow-up period. Twenty-eight patients with necrotic immature roots were assigned to one of two groups: a control group (n = 14) receiving standard regenerative endodontic procedure (REP) with a mock laser application, or an experimental group (n = 14) receiving standard REP with adjunctive low-level laser therapy (LLLT). Both groups underwent initial medication with double antibiotic paste. In the experimental group, a diode dental laser (810 nm, 4.5 J/cm², 0.3 W, 9 s) was applied to the apical third every 48 h for 14 days. After 21 days, intracanal bleeding was induced, and blood samples were collected for regenerative marker analysis using ELISA. Mineral trioxide aggregate was placed, followed by coronal restoration. Clinical symptoms and radiographic healing were monitored over 12 months, with statistical analysis performed using the independent t-test at a 95% confidence level. Clinically, both groups demonstrated high success rates (85.7% in the laser group vs. 78.6% in the control group; p = 0.83). No statistically significant differences were observed when pain and radiographic parameters were compared over time between the groups. Considering the biomarkers, only DSPP expression was significantly higher in the laser group (p = 0.03). For the other biomarkers (VEGF, TGF-β, MMP-8, PDGF-BB), the laser group showed numerically higher mean values, but these differences did not reach statistical significance (all p > 0.05). This study demonstrates that adjunctive low-level laser therapy (LLLT) during regenerative endodontic procedures produced comparable clinical and radiographic outcomes to standard treatment, with a significant increase in DSPP expression suggesting early molecular activation. While these findings indicate potential regenerative benefits, larger multicenter studies with extended follow-up are required to validate LLLT as an adjunct in clinical protocols. Trial registration: This trial was registered in the Clinical Trials Registry India (CTRI) under registration number CTRI/2024/01/062114 dated 31/01/2024.

Traumatic dental injuries are a leading cause of pulpal exposure in immature permanent anterior teeth. Vital pulp therapy (VPT), particularly pulpotomy, has become the preferred treatment modality in such cases as it maintains pulp function, supports physiologic dentin deposition, and promotes long-term tooth retention. However, treatment delays may compromise clinical outcomes due to bacterial contamination and progressive pulpal inflammation. Mineral trioxide aggregate (MTA) and Biodentine™, both hydraulic calcium silicate cements, have demonstrated favorable biological responses in VPT. To evaluate clinical and radiographic outcomes of full pulpotomy using MTA and Biodentine™ in immature permanent teeth with complicated crown fractures and delayed treatment intervals of up to 10 days. This case series included eight immature maxillary central incisors in seven patients, aged 8.5-9.5 years, presenting with complicated crown fractures. Full pulpotomy was performed using either MTA or Biodentine™ following standardized clinical protocols, and teeth were restored in the same visit, with fragment reattachment performed when feasible. Clinical and radiographic follow-up was conducted at 1 week and at 1, 3, 6, 12, 18, and 24 months. At 18-24 months, all treated teeth remained vital, demonstrated resolution of symptoms, and showed continued physiologic root development consistent with successful apexogenesis. A radiographic dentinal bridge was observed in three teeth. No cases exhibited pathological changes such as periapical radiolucency, swelling, or restoration failure, except for one case with crown discoloration. Full pulpotomy using MTA or Biodentine™ may represent a promising treatment option for traumatically exposed immature permanent teeth, even when initiated up to 10 days after injury; however, these findings should be interpreted cautiously in view of the limited sample size and follow-up duration.

Management of necrotic young permanent teeth with incomplete root development represents a significant clinical challenge in pediatric dentistry due to open apices, thin dentinal walls, and increased susceptibility to fracture. Preserving or restoring root development is critical for improving the long-term prognosis of these teeth. Over recent decades, apexification and regenerative endodontic procedures (REPs) have emerged as the primary treatment strategies for addressing pulp necrosis in immature permanent teeth. Apexification aims to induce the formation of a calcified apical barrier that allows effective obturation of the root canal system. Traditionally, calcium hydroxide has been widely used for this purpose, demonstrating high success rates in resolving apical pathology. However, prolonged treatment duration, increased risk of root fracture, and lack of continued root development are important limitations. To overcome these drawbacks, single-visit apexification using bioceramic materials such as mineral trioxide aggregate (MTA) has gained popularity, offering predictable apical barrier formation, reduced treatment time, and favorable clinical outcomes. Regenerative endodontic procedures represent a biologically based treatment approach designed to promote continued root maturation by harnessing the regenerative potential of stem cells from the apical papilla, growth factors, and suitable scaffolds. REPs aim not only to resolve infection but also to facilitate root lengthening, thickening of dentinal walls, apical closure, and reestablishment of vitality-related responses. Clinical studies have reported high survival and success rates for REPs, particularly in teeth with short roots and wide apical openings. This review provides a comprehensive comparison of apexification and regenerative endodontic procedures, focusing on their biological principles, clinical protocols, indications, advantages, and limitations. Emphasis is placed on evidence-based decision-making to guide clinicians in selecting the most appropriate treatment modality based on individual case characteristics. Understanding the strengths and shortcomings of each approach is essential for optimizing clinical outcomes and preserving young permanent teeth in pediatric patients.

This study evaluated the outcome of partial exposure of dentin matrix to ethylenediaminetetraacetic acid (EDTA) and application of platelet-rich fibrin (PRF) scaffold on regeneration of necrotic immature permanent teeth in a dog model. The present study was carried out on 216 permanent immature roots in nine mongrel dogs aged 6-9months. Pulp necrosis and periapical pathosis were induced in 180 roots. These roots were divided into five equal groups (36 roots each) according to the treatment protocol: group I: blood clot; group II: 17% EDTA solution and blood clot; group III: PRF; group IV: 17% EDTA solution and PRF; and group V: without treatment (positive control). The negative control group (group VI) represented 36 untouched normal roots for normal maturation. The groups were followed up for 1, 2 and 3months (subgroups). Maturation of the roots was monitored by radiography and histopathology. All data were statistically analysed. Group IV exhibited the highest increase in root length and thickness, decrease in apical diameter, the highest score of vital tissue infiltration and least inflammatory scores. There was a significant difference regarding the increase in root length and thickness and decrease in apical diameter in all subgroups of the experimental and negative control groups (P≤.05). PRF has a better regenerative potential than the blood clot during treatment of immature permanent teeth with necrotic pulp. Inclusion of 17% EDTA solution as a final irrigation enhances the regenerative potential of both PRF and blood clot.

Regenerative endodontic treatment (RET) has emerged as a biologically based alternative to traditional apexification for managing immature permanent teeth with pulp necrosis. By promoting tissue ingrowth and continued root development, RET aims not only to eliminate infection but also to reinforce structurally compromised roots. Although its clinical use has expanded, evidence regarding the long-term predictability and durability of RET remains limited, as most published studies provide only short- or mid-term follow-up. This report describes two pediatric cases involving regenerative procedures performed on three immature permanent maxillary incisors, each followed for more than six years. The first case involved a 7-year-old girl who developed pulp necrosis in a maxillary lateral incisor after acute dental trauma. Management followed a regenerative protocol using triple antibiotic paste (ciprofloxacin, metronidazole, and minocycline) as intracanal medication and mineral trioxide aggregate as the coronal barrier. The second case concerned an 8-year-old girl presenting with chronic infection and sinus tracts affecting both maxillary central incisors. These teeth were treated using a regenerative approach with calcium hydroxide as the intracanal medicament and Biodentine as the sealing material. Clinical, radiographic, and cone beam computed tomography evaluations demonstrated complete symptom resolution and periapical healing but incomplete progressive apical closure. All treated teeth developed a calcified apical barrier, and outcomes remained stable throughout the extended follow-up period. While inherently limited by the nature of case reports, these findings support RET as a reliable and durable therapeutic option for necrotic immature permanent teeth, including cases in which conventional apexification has not been successful.

The ideal treatment option for immature necrotic permanent teeth is regeneration of the pulp-dentin complex. Mineral trioxide aggregate (MTA), the conventional cement used for regenerative endodontic procedures, induces hard tissue repair. Various hydraulic calcium silicate cements (HCSCs) and enamel matrix derivative (EMD) also promote osteoblast proliferation. The purpose of the present study was to determine the osteogenic and dentinogenic potential of commercially distributed MTA and HCSCs when applied in combination with Emdogain gel on human dental pulp stem cells (hDPSCs). The presence of Emdogain resulted in greater cell viability, and higher alkaline phosphatase activity was detected in the Emdogain-supplemented groups in the early days of cell culture. On qRT-PCR, the groups treated, respectively, with Biodentine and Endocem MTA Premixed in the presence of Emdogain showed an increased expression of the dentin formation marker DSPP, and the group treated with Endocem MTA Premixed in the presence of Emdogain showed an upregulated expression of the bone formation markers OSX and RUNX2. In an Alizarin Red-S staining assay, all of the experimental groups exhibited a greater formation of calcium nodules when treated in combination with Emdogain. Overall, the cytotoxicity and osteogenic/odontogenic potential of HCSCs were similar to that of ProRoot MTA. The addition of the EMD increased the osteogenic and dentinogenic differentiation markers.

Root fractures in immature teeth are rare because the resilience of the alveolar bone is more favorable to the occurrence of luxation. This article reports a case of traumatic injury in an immature permanent tooth that progressed to root fracture, having a parafunctional oral habit as the possible modifying factor of case evolution. A 12-year-old boy presented for treatment complaining of a defective restoration and mild pain on the maxillary right central incisor. The patient had a history of crown fracture in this tooth due to trauma 2 years before. The clinical examination showed healthy gingival tissues and no abnormal tooth mobility, whereas radiographic projections revealed healthy periradicular tissues, incomplete root formation, and no visible root fracture. As pulp necrosis was diagnosed, calcium hydroxide therapy was started for canal disinfection and subsequent obturation. However, after 4 weeks of treatment, a horizontal fracture line was observed radiographically in the root's middle third. The patient denied a new traumatic injury, but revealed the habit of chewing on a pencil. Refraining from the deleterious oral habit was strongly advised, and root canal filling with mineral trioxide aggregate was performed to treat the root fracture. After 4 years of follow-up, the tooth has normal function and no abnormal mobility. Images suggestive of remodeling at the apical end of the coronal segment and replacement resorption of the apical segment are seen radiographically. This case demonstrates the need of following cases of dental trauma and the possible influence of parafunctional oral habits as modifying factors of case progression.

The current study aimed to determine how the disinfection strategy for regenerative endodontic procedures (REPs) influences overall bacterial load and REP outcomes. Different bacterial species in the teeth were also examined in this study. A previously reported non-randomized controlled clinical research on REP ± leukocyte and platelet-rich fibrin gathered microbial samples from 14 of 29 patients during REP (LPRF). Four microbiological samples were obtained in two treatment sessions. S1 and S2 were taken before and after the first irrigation with 1.5% NaOCl and saline. Samples S3 and S4 were obtained before and after rinsing with 17% EDTA in the second treatment session. Microbial samples were identified using a quantitative polymerase chain reaction with species-specific primers. The total bacterial load recovered from patients showed a significant (p < 0.05) decrease after the first treatment and was maintained throughout the second treatment. Fusobacterium nucleatum, Treponema denticola, and Enterococcus faecalis were the most prevalent species in root canals, detected in all analyzed cases (100%), followed by Prevotella intermedia and Tannerella forsythia, both in six of 14 (42.9%) cases. The presence of these abundant species was significantly reduced after sample S1 was obtained. Parvimonas micra was present in four of 14 (28.6%) cases and Actinomyces naeslundii in two of 14 (14.3%) cases. Filifactor alocis, Porphyromonas endodontalis, and Porphyromonas gingivalis were each detected in only one of 14 (7.1%) cases. No statistical correlation could be made between bacterial species and clinical or radiographic outcomes due to the small sample size. In the LPRF group, two cases required retreatment due to early post-treatment flare-up, and two other cases presented radiographically presented a persistent apical periodontitis 3 years after treatment. In the control group, all analyzed cases were clinically asymptomatic after treatment, and radiographically, the final periapical index score at the last recall revealed healthy periapices. The REP disinfection protocol of the present study seems to be satisfactorily effective in reducing the total bacterial load, omitting clinical symptoms and inducing periapical bone healing in immature permanent teeth with pulp necrosis. However, LPRF seems to prevent these outcomes from being achieved and should consequently therefore not be recommended in REPs.

Apexification, a well-established endodontic treatment for managing immature permanent teeth with pulp necrosis, aims to create a calcified apical barrier to seal communication with the periapical tissues and allow gutta percha placement. This literature review explores advancements of apexification and introduces a systematic, evidence-based procedure for achieving optimal outcomes for apexification procedures. The discussion compares the materials most commonly used in apexification: calcium hydroxide [Ca(OH)2], mineral trioxide aggregate (MTA), and Biodentine. Compared with Ca(OH)2, contemporary calcium silicate-based materials such as MTA and Biodentine have significantly greater predictability, biocompatibility, and fracture resistance, increasing the longevity of the immature tooth. In addition, the article discusses alternatives to apexification, including regenerative endodontic therapy. A review of the scholarly literature reveals that apexification has long been a cornerstone of treatment for immature permanent teeth with necrotic pulp, offering a predictable method to create a calcified barrier at the apex and enable tooth restoration. While apexification does not promote further root growth, it remains a reliable solution, particularly for cases requiring immediate treatment and a high degree of predictability.