Apexogenesis treatment with mineral trioxide aggregate: long-term follow-up of two cases. Private Practice, Midrand, South Africa. Apexogenesis is the treatment of choice for traumatized or carious teeth which, at the time of exposure, have a vital pulp and open apex. This article describes two cases of permanent teeth with carious exposures, treated with direct pulp capping procedures using mineral trioxide aggregate MTA. METHODS: Radiographic and clinical examination, including testing reaction to cold, showed that both teeth were immature and in a stage of reversible pulpitis. The caries was identified using caries detector dye and removed using a rotary bur.
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Reestablishing blood flow and allowing the continuation of root development are some of the objectives of pulp revascularization. This procedure is currently indicated for teeth with incomplete root formation as an alternative to the traditional treatment of apecification, which consists of inserting calcium hydroxide paste into the root canal for a determined time period in order to induce the formation of a calcified barrier. Although it is considered as the most classically employed therapy, the permanence of the paste for long time periods may lead to the weakening of the root due to hygroscopic properties, as well as proteolytic activities of calcium hydroxide.
Therefore, there has been a permanent search for alternatives which allow the full development of immature teeth. Revascularization has emerged as such an alternative, and a range of treatment protocols can be found in the scientific literature.
The aim of this paper is to accomplish a literature review concerning this issue. Conventional endodontic treatment consists in the development and application of techniques designed to accomplish the chemical-mechanical preparation of root canals in order to eliminate an infection, many times difficult to combat due to the complexity of the root canal system. However, this process may become even more complicated in cases of immature teeth with open apexes, whose root walls are fragile due to the thin thickness of the root canal dentin, along with the intense activity and anatomy of an open apex, making it difficult to accomplish the complete obturation of the canal, and with the real risk of solid and plastic material overflow into the periapex.
The incomplete root development may be caused by trauma or infections powerful enough to halt mineral deposition by the destruction of blood flow, impeding the root to complete its formation [ 1 ]. One way to treat open apex teeth is the apexification technique that is made in pulpless teeth and which promotes apical closure, and can be obtained with the insertion of a MTA Mineral Trioxide Aggregate barrier or with periodical exchanges of calcium hydroxide, enhancing further obturation.
This process is named apexogenesis and its goal targets at the preservation of vital pulp tissue so that the continued root development with apical closure may occur [ 2 , 3 ]. Nevertheless, some studies have shown that this protocol can also be used in non-vital teeth. The procedure is named pulp revascularization and is directed by disinfection protocols concerning the root canals, being indicated the use of sodium hypochlorite irrigation NaOCl followed by a combination of ciprofloxacin, metronidazole and minocycline antibiotics to be used as intracanal medication [ 4 ].
The aim of this work is to accomplish a literature review concerning pulp revascularization and its efficacy as a Regenerative Endodontic Procedure. Bacterial, mechanical or physic-chemical factors are powerful enough to harm the pulp, leading to vascular changes and inflammation, the pain being described as execrating and almost intolerable, and making the patients search for dental help.
The first attempts to regenerate the pulp tissue were conducted by Nygaard Ostby [ 6 , 7 ]. In both studies, the root canals were intentionally overinstrumented to evoke bleeding followed by the obturation with gutta-percha and Kloroperka N-O paste short of the root apices to allow tissue ingrowth into the root canal space.
The histological examinations of these showed mineral tissue deposition along the root canal walls and connective tissue. With the importance of infection control in mind and considering the conditional role of microorganisms within the root canals, Rule and Winter [ 8 ] introduced polyantibiotics consisting of a mixture of neomycin sulfate, polymyxin B sulfate, bacitracin, and also nystatin, associated with absorbable iodoform into the root canals, which caused a thicker and continued root development as well as an apical barrier formation in pulpless teeth.
As the researches went on, Nevins and collaborators [ 9 , 10 ] reported revitalization and hard tissue formation in immature pulpless teeth in monkeys and humans when root canals were mechanically instrumented and collagen—calcium phosphate gels were used as a scaffold. Although the presence of hard tissue formation began to be discussed in the dental community, it was also observed that the teeth treated with this therapy were more prone to fracture under stress due to the thin dentin walls, and so it became only natural and expectable that scientists would find out a way to stimulate the organism to complete root development, including the apex closure, opening the era of Regenerative Endodontic Procedures REP , designed to predictably replace damaged, insufficient and missing structures by healthy newly produced tissues, restoring the shape and function of the pulp-dentin complex.
The new approaches included: direct pulp capping, revascularization, apexogenesis, apexification. Stem cell therapy, and tissue engineering are the most up to date ones [ 11 ]. Regenerative Endodontic Procedures so have emerged as a viable, easy doing alternative to allow the complete formation of the roots of immature teeth, mainly in the last decade.
REPs work with the prerogative that the root canal space free of contamination associated with a new stimulated blood supply can indeed reestablish vascularization, enhancing root completion the gap between the theory and clinical applications has been narrowed, and researches are now converging to regenerative procedures [ 12 , 13 ].
Only in was pulp revascularization procedure globally available in the internet by Trope [ 14 ] who described it and applied the technique in a lower right second premolar with open apex, with clinical and radiographic aspects of apical periodontitis, with the presence of a fistule.
Irrigation was accomplished with 5. Clinical and radiographic healing could be observed after 22 days. The author claimed that if revascularization is not reached in a period of three months, conventional treatment is then indicated.
Kvinnsland [ 15 ] reported a case of a 9-year-old patient with history of trauma in the upper central incisors. After clinical and radiographic examination, the diagnosis of concussion was obtained and emergency dental assistance took place. A month later the patient reported slight symptoms in the area, being diagnosed with periapical periodontitis.
The root canal was then instrumented and irrigated with 0. Four months later, root formation began to be visualized, and the exchange of intracanal calcium hydroxide was made, and periodical radiographs were accomplished every 3 months, which revealed continuous root formation and apical closure.
The authors reported that the kind of pulp response varies, not only according to the type of the traumatic injury, but also concerning the action of progenitor cells implied in the process. Still according to them, tissue repair may be initiated from pulp progenitor cells, periodontal tissues or by the combination of both. If the damaged pulp tissue is renewed by pulp progenitor cells, there seems to be repair by the action of dental pulp stem cells DPSCs which can be induced, at least in vitro , to differentiate into odontoblastic phenotype, characterized by polarized cells and mineralized nodules [ 16 , 17 ], while producing newly formed dentin which can be reinnervated by sensorial nerves.
Shimizu [ 18 ] defined regeneration as the replacement of damaged tissues by the same type of parenchyma cells previously existent in that tissue. With the aim of scrutinizing histological aspects of a tooth with incomplete root formation and diagnosed with irreversible pulpitis, the authors described a case report of a year-old boy who underwent revascularization therapy and showed normal periapical tissues after the treatment, accomplished with a MTA barrier.
However, the tooth was fractured soon after and needed to be extracted. The majority of the cells in the root canal space, especially in the periapical area, were classified as fusiform cells, fibroblasts or mesenchymal cells, with more blood vessels and cells in the root canal than in the apical zone.
The authors concluded that revascularization and regeneration of a permanent tooth with incomplete root formation and irreversible pulpitis, involving the pulp tissue in the apical portion of the root canal may indeed have the potential of pulp tissue regeneration. In the study of Pramila and Muthu [ 19 ], the authors reported the results of treatments in patients with incomplete root formation of permanent teeth, with and without pulp vitality.
Twenty four hours later the teeth were sealed with glass ionomer GIC. In necrotic teeth, after disinfection, clot formation was stimulated. The authors concluded that under certain circumstances, teeth with necrotic pulps and open apexes are able to regenerate pulp tissue and to promote hard tissue production associated with root growth and complete apex formation.
Aggarwal [ 20 ], in , compared the apexification accomplished with calcium hydroxide and pulp revascularization in a single year-old female patient, but in different teeth. The patient complained of pain, edema and mobility in the upper central incisors and purulent discharge in the frontal upper region of the face. She gave a history of trauma around 15 years before, and her medical history was noncontributory.
In the radiographs, incomplete rhyzogenesis could be observed along with thin radicular walls. Both the central incisors had grade I mobility and the intraoral radiographs also revealed immature apices associated with both maxillary central incisors, but with no signs of fracture despite the fact that the walls of the canals were very thin.
Irrigation was made with 5. Calcium hydroxide paste was inserted in the root canal of tooth 11, while in tooth [ 21 ], a three antibiotic creamy paste and provisory sealing with zinc eugenol sealer took place. Two weeks later, these procedures were repeated, and after two months tooth 11 were obturated with guttapercha, while tooth 21 underwent revascularization procedure, by inducing apical bleeding.
After this period, there was no perceptible mobility in both teeth, and root formation was reached with apical closure in tooth The authors demonstrated that the revascularization technique resulted in better healing and apical maturation. Still in , Lenzi and Trope [ 21 ] described the treatment of two non-vital central incisors with incomplete rhyzogenesis due to trauma.
The 8-year-old male patient had coronary fracture in tooth 11 and After coronary opening, rubber dam placement and determination of the working length, copious irrigation was firstly accomplished with 2. After 35 days the teeth were anesthetized, and the canals were accessed and irrigated with sterile saline solution, and a small bleeding was stimulated.
At the 4-month follow-up examination, the patient was asymptomatic and the periapical radiographs showed a slight indication that the walls were thickening in the upper right maxillary incisor. At the month follow-up, the patient was still asymptomatic and the revitalization of the root canal was performed since the upper right maxillary incisor showed a distinct thickening of the dentinal walls and closure of the apex of the root, while the upper left maxillary incisor displayed evidence of revitalization.
Finally, At the month follow up the patient remained asymptomatic and the successful revitalization of the upper right maxillary incisor was accomplished while the upper left maxillary incisor had not revitalized, but the radiopaque hard-tissue barrier at the apex of it was more distinct. The authors conclude that the complete understanding for the criteria for predictable revitalization and apexification is still lacking.
Kim et al. After clinical and radiographic examination, he was diagnosed with pulp necrosis and symptomatic apical periodontitis. Under anesthesia, the root canal was accessed and irrigated, filled with a creamy paste mixture of metronidazole Samil Pharm, Seoul, Korea , ciprofloxacin Sinil Pharm, Seoul, Korea and cefaclor Myungin Pharm, Seoul, Korea in sterile saline was applied with the aid of a lentulo-spiral and tapped down into the canal with the blunt end of sterile paper points.
Then with the aid of a No. A six-week follow-up showed that the periapical radiolucency had diminished, and the month follow-up finally displayed a completely closed root apex with no periapical pathosis detected.
In the second case, a year-old- patient with moderate to severe pain and swelling in the mandibular left second molar was treated. The same methodology as the first case was applied and 42 months later the patient was asymptomatic and without apical periodontitis. The third case was also accomplished in a young patient as it was in case 2. Following six months of the mandibular left second premolar revascularization, a slight swelling was observed on its buccal surface.
During clinical examination, the tooth showed sensitivity to vertical and negative response to percussion tests. Following the radiographic examination, an apical radiolucent image was detected, as well as an incomplete root formation. After complete isolation and anesthesia, the root canal was accessed and there was evident purulent secretion.
In the second session, there was regression of the edema, followed by the removal of Caviton and all the creamy paste. Two weeks later, the patient was asymptomatic and the root canal was obturated and the tooth restored with composite resin Z; 3M ESPE. After two months, the apical lesions regressed, and 42 months later an increase in the root thickness was observed. The authors concluded that long term forecasts are positive for the revascularization of necrotic teeth with incomplete root formation.
Dens invaginatus is a rare odontogenic formation which happens before the biological mineralization occurs. Treatment options for dens invaginatus include preventive sealing or the filling of the invagination, endodontic treatment, endodontic surgery, intentional reimplant or extraction.
Yang et al. The tooth was sensitive to percussion and palpation, low mobility grade 2 with indication of apical lesion rather than periodontal. The periapical X-ray and cone beam computed tomography CT scan revealed type II invagination, which extended from the crown to the middle root.
The tooth had pulp necrosis and was isolated under local anesthetic, followed by coronary access with no signs of exudation. Soon after, a second root canal was found. Before instrumentation, the canal was irrigated with 30ml of 5. At the following appointment, the patient was partially relieved from the symptoms.
After 4 consecutive weeks of medication and irrigation, the patient was completely asymptomatic; there was no sensitivity to percussion or palpation, and no edema. Only after irrigation with 2. Periodical R-ray examinations made every month showed that the periapical radiolucency progressively regressed.
Two years later the patient remained asymptomatic, and a periapical X-ray and CT scan revealed that the radiolucent periapical lesion was completely healed, with apical closure and thickening of the root canal walls. The authors conclude that pulp revascularization is an effective new treatment protocol for immature permanent teeth with periapical periodontitis.
The study of Forghani et al. On clinical examination, coronary fractures on both maxillary upper central incisors were detected. The upper right central incisor had a large pulp exposure, sensitivity to palpation and percussion and swelling in the buccal mucosa; and responded negatively to thermal test, being diagnosed as pulp necrosis with an acute periapical abscess.
The upper left central incisor had a pinpoint pulpal exposure and no sensitivity to vertical percussion, being diagnosed as irreversible pulpitis.
Radiographically, both fractured teeth had immature apices, and a radiolucent periapical lesion around the apex of the right central incisor.
Pulp Revascularization: A Literature Review
Carious exposure of an irreversibly inflamed vital pulp in a young permanent tooth presents a significant clinical challenge to maintain vitality. Direct pulp capping, partial pulpotomy and complete pulpotomy are the available procedures to treat young permanent tooth. Currently, calcium hydroxide is the material of choice for apexogenesis. The present case report describes the successful apexogenesis of mandibular left first permanent molar using calcium hydroxide-chlorhexidine paste within 7 months and also discussed prognostic and technique guidance. Partial pulpotomy for immature permanent teeth: It's present and future. Pediatr Dent ;
Apexification, Apexogenesis and Regenerative Endodontic Procedures: A Review of the Literature
Reestablishing blood flow and allowing the continuation of root development are some of the objectives of pulp revascularization. This procedure is currently indicated for teeth with incomplete root formation as an alternative to the traditional treatment of apecification, which consists of inserting calcium hydroxide paste into the root canal for a determined time period in order to induce the formation of a calcified barrier. Although it is considered as the most classically employed therapy, the permanence of the paste for long time periods may lead to the weakening of the root due to hygroscopic properties, as well as proteolytic activities of calcium hydroxide. Therefore, there has been a permanent search for alternatives which allow the full development of immature teeth. Revascularization has emerged as such an alternative, and a range of treatment protocols can be found in the scientific literature.
Apexification, apexogenesis and regenerative endodontic procedures: a review of the literature.
Aim: Aim of this paper was to present the therapeutical approaches to the management of the immature apex and discuss the evolution of materials and techniques. Methods: A Medline search was performed limited to human studies published. The keywords searched were apexogenesis, apexification, pulp regeneration, revascularization. Results: Apexogenesis and apexification techniques using Calcium hydroxide or MTA give a high succes rate. Recent regeneration procedures may be helpful for apexification in non vital elements. Conclusion: Calcium hydroxide is the gold standard material used in apexogenesis and apexification. New technologies are promoting the growing interest in strategies used for vitality preservation and pulp regeneration.