Regenerative Endodontic Procedures Using Contemporary Endodontic Materials

Abstract

Calcium hydroxide apexification and Mineral Trioxide Aggregate (MTA) apexification are classical treatments for necrotic immature permanent teeth. The first tend to fail for lack of compliance given the high number of sessions needed; the second has technical difficulties such as material manipulation and overfilling. With both techniques, the root development is interrupted leaving the tooth with a fragile root structure, a poor crown-to-root ratio, periodontal breakdown, and high risk of fracture, compromising long-term prognosis of the tooth. New scientific literature has described a procedure that allows complete root development of these specific teeth. This regenerative endodontic procedure (REP) proposes the use of a combination of antimicrobials and irrigants, no canal walls instrumentation, induced apical bleeding to form a blood clot and a tight seal into the root canal to promote healing. MTA is the most used material to perform this seal, but updated guidelines advise the use of other bioactive endodontic cements that incorporate calcium and silicate in their compositions. They share most of their characteristics with MTA but claim to have fewer drawbacks with regards to manipulation and aesthetics. The purpose of the present article is to review pertinent literature and to describe the clinical procedures protocol with its variations, and their clinical application.

Keywords: Immature permanent tooth; necrotic pulp; regenerative endodontics; revascularization; revitalization.

Figure 1

(A) Pre-operative radiograph of a young necrotic upper left central incisor with periapical lesion; (B) radiograph after two months medication with calcium hydroxide; (C) radiograph after six months medication with calcium hydroxide; (D) working length determination; (E) post-operative radiograph; (F) four-years control radiograph.

Figure 2

(A) Pre-operative radiograph of a young necrotic upper left central incisor with open apex and a periapical lesion; (B) radiograph of the MTA apical plug; (C) post-operative radiograph; (D) 2-years control radiograph; (E) intra-operative image of the open apex; (F) intra-operative image of the MTA apical plug.

Figure 3

(A) Pre-operative radiograph of a young necrotic upper left central incisor with open apex and a periapical lesion; (B) radiograph of the calcium hydroxide medication; (C) working length radiograph of the file inducing bleeding; (D) radiograph of the coronal barrier positioned; (E) 6-months control radiograph; (F) 1-year control radiograph; (G) 2-years control radiograph; (H) 3-years control radiograph; (I) 3-years clinical image.

Scheme 1

Comparison between American Association of Endodontists (AAE) (adapted from [77]) and European Society of Endodontology (ESE) protocols (adapted from [79]).

Scheme 1

Comparison between American Association of Endodontists (AAE) (adapted from [77]) and European Society of Endodontology (ESE) protocols (adapted from [79]).

Scheme 1

Comparison between American Association of Endodontists (AAE) (adapted from [77]) and European Society of Endodontology (ESE) protocols (adapted from [79]).