Regenerative endodontics: a true paradigm shift or a bandwagon about to be derailed?

Abstract

Aims: Regenerative endodontic techniques (RETs) have been hailed as a paradigm shift for the management of traumatised non-vital immature permanent anterior teeth. In this article the aim was to critically appraise the literature with regards to the outcome of regenerative endodontics on root development.

Methods: Critical review of the literature where regenerative endodontic techniques have been used in the management of immature non-vital teeth with continuation of root development as the main outcome reported.

Results: Most studies published were in the form of case reports and series with very few randomised controlled trials with a high risk of bias. Continuation of root development following the use of RET has been shown to be unpredictable at best with lower success in those teeth losing vitality as a result of dental trauma.

Conclusions: Despite the high success of regenerative endodontics in terms of periodontal healing including resolution of clinical and radiographic signs and symptoms of infection, continuation of root development remains an unpredictable outcome. The use of a blood clot as a scaffold in regenerative endodontics should be reviewed carefully as that might offer an environment for repair rather than regeneration. In addition, preservation of structures, such as Hertwig's epithelial root sheath, may have an important bearing on the success of this approach and should be further investigated.

Keywords: Non-vital immature teeth; Regenerative endodontics; Revascularisation.

Fig. 1

Periapical radiograph showing cervical root fracture of a tooth treated with calcium hydroxide apexification

Fig. 2

Clinical photographs and radiographic examination of two cases treated with regenerative endodontic technique showing success and survival outcomes. a Photograph showing labial abscess with discharging sinus related to the non-vital 12 secondary to dens invaginatus. b Photograph showing resolution of signs of infection (swelling and discharging sinus) maintained for up to 24 months following RET treatment of 12. c–f Periapical radiographs taken at baseline (showing an immature 12 with <1/2 root formation, thin dentinal walls and wide open apex), and follow-up at 3 months, 9 months and 2 years showing complete success following RET with gradual root formation and thickening of dentinal root walls. g Photograph showing traumatised non-vital 21 which sustained an enamel/dentine fracture. h Photograph showing no signs of infection (swelling and/or discharging sinus) at 24 months following RET treatment of 21. i–l Periapical radiographs taken at baseline (showing an immature 21 with <2/3 root formation, thin dentinal walls and wide open apex), and follow-up at 3 months, 9 months and 2 years showing no evidence of periapical lesion and with no signs of continuation of root development nor thickening of dentinal walls. The apical root canal space (l) shows evidence of radiopaque trabeculation suggestive of bony ingrowth

Fig. 3

Clinical photographs (a before treatment, b 2 years following RET) and radiographs (c baseline immediately after treatment, d 3 months, e 9 months, f 2 years following RET) of an avulsed and replanted immature 21 treated with RET. No signs of infection were evident after 2 years with continuation of root developmemt, minimal replacement resorption and no signs of infra-occlusion seen at 2 years follow-up