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Table of Contents
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 134-141

Revascularization of nonvital immature incisor with asymptomatic apical periodontitis

Department of Conservative Dentistry, Faculty of Dentistry, Gadjah Mada University, Yogyakarta, Indonesia

Date of Submission02-Jul-2020
Date of Decision24-Aug-2020
Date of Acceptance15-Sep-2020
Date of Web Publication17-Oct-2020

Correspondence Address:
Department of Conservative Dentistry, Faculty of Dentistry, Gadjah Mada University, Yogyakarta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_25_20

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Background: The management of immature central incisors with nonvital pulp is a challenge for dentists because the goals and criteria for successful root canal treatment are difficult to achieve. A necrotic immature root canal system accompanied by apical periodontitis cannot be disinfected by standard protocols with the aggressive use of endodontic files. This case report demonstrated the advantages of pulp revascularization as a treatment method for necrotic immature teeth based on clinical and radiographic outcomes. Case Report: The patient was an 11-year-old boy with a history of trauma to the upper left central incisor who was treated with a revascularization procedure. Clinical and radiographic evaluations showed nonvital pulp, asymptomatic apical periodontitis, and mucogingival swelling before treatment. At the 1-, 3-, and 6-month follow-up visits, the patient's teeth remained asymptomatic and well-functioning. There was a slight thickening of the tooth wall and loss of lesions, although total closure of the apical foramen was observable. Longer clinical and radiographic controls are needed to evaluate the success of this case.Conclusion: Revascularization is a procedure that promotes thickening of the dentinal wall and closure of the apical foramen, thereby preventing teeth from becoming weak. The minimum expectation of revascularization treatment is the absence of undesirable signs and symptoms, but the ultimate goal is full regeneration of the pulp complex and ideal root development.

Keywords: Apexification, immature teeth, necrosis, periodontitis, revascularization

How to cite this article:
Doni, Mulyawati E, Santosa P, Nugraheni T. Revascularization of nonvital immature incisor with asymptomatic apical periodontitis. Sci Dent J 2020;4:134-41

How to cite this URL:
Doni, Mulyawati E, Santosa P, Nugraheni T. Revascularization of nonvital immature incisor with asymptomatic apical periodontitis. Sci Dent J [serial online] 2020 [cited 2023 Jun 4];4:134-41. Available from: https://www.scidentj.com/text.asp?2020/4/3/134/298464

  Background Top

The management of immature teeth with nonvital pulp is a challenge for dentists because the goals and criteria for successful root canal treatment are difficult to achieve. Conventional apexification is performed using a long-term calcium hydroxide paste to close the apex to enable further filling of the root canal. Other alternative techniques use mineral trioxide aggregate (MTA) materials, which do not require periodic replacement of intracanal materials. Both of these techniques have the same disadvantages: they do not stimulate Apexogenesis, cause roots to remain short and weak, and increase the risk of fracture.[1] Apexifcation treatment using calcium hydroxide2 and MTA3 have high risks such as reinfection and tooth fracture exist. Another disadvantage is tooth mobility due to the poor ratio of crowns to tooth roots.[4]

Necrotic immature root canals accompanied by apical periodontitis cannot be disinfected with standard protocols using aggressive endodontic files. Likewise, after the disinfection phase is complete, the obturation of the root canal is more difficult because the open apex does not provide a barrier when filling. Further, the roots of these teeth are thin and have a high susceptibility to fractures. These problems are overcome by implementing a disinfection protocol with minimal instrumentation, stimulating the formation of artificial apical barriers to enable optimal filling of channels, and strengthening roots.[5]

Revascularization is a treatment method for necrotic immature permanent teeth that will make the teeth vital, helping in the development of sustainable roots and thickening of the dentin wall.[6] There are many case reports of revascularization not only in single-rooted teeth but also in teeth with many roots.[7]

Revascularization is recommended as an alternative to apexification in irreversible pulpitis or pulp necrosis, both associated with or without apical periodontitis.[8] An organic-based approach enables continued root development and recovery of pulp vitality. The preparation of root canals for revascularization consists of passive chemomechanical cleaning and shaping performed with manual instruments and chemical additives that are antimicrobial and low toxicity, placement of antimicrobial drugs, and induction of bleeding.[1]

Revascularization was introduced as an alternative to apexification in 2001. Iwaya et al. reported the success of radiographic immature necrotic immature teeth in the 5th month, which showed an increase in tooth wall thickness, apical foramen closure, and periodontitis regression. The root canal decontamination process was carried out using chemical additives and an antibiotic paste, followed by a final coronal restoration.[9]

Revascularization can be defined as an invagination of undifferentiated periodontal cells from the apical region in immature teeth.[10] Pulp revascularization is a regenerative treatment of necrotic immature teeth that involves inducing the formation of a blood clot within the previously disinfected canal by involving the recruitment of stem cells from the apical region.[11] There are currently two approaches to pulp tissue regeneration. The first is revascularization, where new pulp tissue is expected to grow into the root canal from the remaining tissue in the root canal.[12] The second approach is the replacement of diseased pulp with healthy tissue, which can revitalize teeth and restore the dentin formation process.[13] According to Windley et al., the success of revascularization of immature teeth with apical periodontitis mainly depends on the disinfection of the canal, placement of a barrier in the canal to facilitate tissue growth, and sealing to prevent bacterial access.[14]

The purpose of this paper is to present a case report of pulp revascularization as an example for dentists wishing to perform this procedure. In this paper, we report the revascularization treatment of nonvital immature permanent central incisors accompanied by asymptomatic apical periodontitis in an 11-year-old male. The minimum expectation of the treatment is the absence of undesirable signs and symptoms, but the ultimate goal is full regeneration of the pulp complex and ideal root development.[15],[16]

  Case Report Top

An 11-year-old male patient presented to the Dental Conservation Clinic, Dental Hospital Prof. Soedomo, Faculty of Dentistry, Universitas Gadjah Mada, because he was referred by a dentist for pulp treatment on his upper front teeth. The gums around his teeth had been swollen since he first visited the dentist a week ago. About 2 months ago, he had an accident and fell on the asphalt, causing the tooth to break. In the last 2 weeks, his gums were swollen, sore, and the dentist prescribed antibiotics, pain relievers, and anti-inflammatory drugs. The patient had no history of allergies and did not suffer from any systemic disease.

Clinical examination showed that tooth 21 had an Ellis Class III fracture, no caries, and had a negative response to the vitality and negative tests while the mobility and percussion tests were positive [Figure 1]. Preoperative radiograph 21 showed a fracture of the half-crown of the tooth that had already hit the pulp, and the radiolucent image was not firmly demarcated in the apical part. In addition, the apical tip remained open, and the root canal was still wide enough. Tooth 11 had a crown fracture on one-third of the mesial incisal, and the apical tip was not completely closed. A radiolucent boundary was not visible around the apical, and there was a widening of the periodontal ligament along the root of tooth 21 [Figure 2].
Figure 1: Clinical examination showed Ellis Class III fracture on tooth 21 from frontal plane (a) and intraoral images of upper (b) and lower jaw (c)

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Figure 2: Preoperative radiographs of teeth 21 and 11 (a), cone-beam computed tomography coronal view (b), and sagittal tooth 21 (c). There was a diffuse radiolucent appearance in the periapical root area

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The radiographic interpretation of cone-beam computed tomography (CBCT) from the frontal aspect was radiolucent in the incisal mesial of tooth 21, indicating that the tooth fracture had reached the pulp. The sagittal aspect showed widening of the periodontal ligament space in the apical of tooth 11, the apical portion of tooth 21 was not yet fully formed, the width of the apical foramen was around 1.07 mm, there was a widening of the periodontal ligament space, and there was disruption of the lamina dura at the apical of tooth 21. The radiodiagnosis conclusion was apical periodontitis of teeth 11 and 21.

First appointment

Informed consent was signed by the child's parents, who were told that this was a relatively new procedure without standard protocols. The working area was isolated with a rubber dam. K-file no. 40 was used to determine the short working length from radiographic photographs, reduced by 2 mm, then confirmed by radiographs, and a working length of 19.5 mm was obtained. Biomechanical preparation was minimally performed with K-file no. 40 with a circumferential filing technique on the entire root wall. Irrigation was carried out using 20 ml of a 1.25% NaOCl solution with an irrigation needle with a 30G single-side vent tip. The working length was reduced by 1 mm to clean debris and the remaining necrotic tissue in the root canal. This was followed by irrigation with 2.5–20 ml of EDTA 17% to remove the smear layer in the root canal wall, thereby enabling the medicament material to penetrate the dentinal tubules in the root canal. Next, rinsing was performed with distilled water. Root canal 21 was dried with sterile paper points, and then, triple antibiotic paste (TAP) (metronidazole, ciprofloxacin, and minocycline) was placed in the coronal section. The cavity was closed with a temporary lift (Caviton, GC). The patient was instructed to return 1 week later.

Second appointment

Subjective and objective examinations were performed. The patient did not feel any pain after the treatment, the temporary restoration was in good condition, and percussion and palpation were negative. Local infiltration anesthesia using 3% mepivacaine with vasoconstrictor was injected on tooth 21 areas. Tooth 21 was isolated using a rubber dam, and a temporary lift was opened. Root canals were irrigated with 17% EDTA up to 20 mL, rinsed with distilled water, and then dried with a sterile paper point. New bleeding was made by over-instrumentation using sterile K-file no. 20, which was inserted 23 mm into the root canal. After the bleeding almost reached the orifice (±15 min), Spongostan was inserted into the root canal to help with coagulation. MTA was stirred with sterile distilled water to form the consistency of wet sand and was applied to the apical orifice along 4 mm. The MTA was compacted using a plugger. MTA density was confirmed using radiography. Moist cotton was placed in the pulp chamber to induce the hardening of the MTA material for 24 h, along with a temporary layer of glass-ionomer cement (GIC). The patient was instructed to return 1 week later. The dental revascularization procedures performed at the first and second appointments were guided by Jung et al., as shown in [Figure 3].[17]
Figure 3: Schematic illustration of dental revascularization procedure of Jung et al. (2019) compared side by side with clinical procedures, including preoperative (a), open access (b), K-file insertion to calculate tooth length and working length (c), 1.25% NaOCl solution (20 mL/canal, 5 min) and 17% EDTA for disinfection (d), root canal drying with paper point (e), intracanal medication and temporary restriction (f). Final irrigation with saline and EDTA 17% (g), dry root canal (h), over-instrumentation (i), scaffolding (j), placement of mineral trioxide aggregate above (k), and the process of tooth regeneration begins (l)[1]

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Seven-day follow-up

Subsequent examination revealed that the patient did not feel any pain after the treatment, the temporary lifts were in good condition, and percussion and palpation were negative. Teeth were isolated with a rubber dam. A temporary lift and moist cotton in the pulp chamber were cleaned. GIC material was applied as a barrier in the orifice. Tooth cavity 21 was etched using 37% phosphoric acid for 15 s using the total-etch technique. Bonding was applied with a micro brush, allowed to stand for 10 s, and then, light air was blown onto the area using a three-way syringe for 10 s. This was followed by light curing for 20 s. A2 color composite resin was applied as the final restoration and shined for 20 s in stages. The rubber dam was removed, and the occlusion and polishing were checked [Figure 4].
Figure 4: Stages of post revascularization restoration from mock up (a), tooth color determination using the Vita Classic shade guide (b), teeth preparation (c-d), etching (e), bonding (f), base application (g-h) and palatal guide application (i), also using TOR Proximal anterior strips for contouring (j) fnishing, and polishing (k and l)

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One-, 2-, and 6-month follow-up visits

Based on subjective and objective examinations, the patient did not feel any pain after the treatment. The temporary lifts were in good condition, and percussion and palpation were again negative. Radiographic examination of tooth 21 showed that periapical radiolucency had shrunk, and the root wall had thickened.

Follow-up visits were conducted at 1, 2, and 9 months, and the patient's teeth remained asymptomatic and functioning properly. There was a little thickening of the root canal wall, and total closure of the apical foramen was observed. Longer clinical and radiographic controls are needed to observe the success of this case for a period of 2 years. Percussion and palpation tests were all negative, while thermal and electric pulp tests indicated a positive response. Periapical radiographic examination revealed a loss of radiolucency in the apical section and reduced periodontal ligament widening of the 21 involved tooth roots at the 1-, 3-, and 9-month (more than 6 months) follow-ups compared with the preoperative radiographs [Figure 5]a, [Figure 5]b, [Figure 5]c, [Figure 5]d, [Figure 5]e, [Figure 5]f.
Figure 5: Preoperative radiography (a); confirm K-File before minimal root canal preparation (b); postmineral trioxide aggregate barrier application (c); 1-month (d), 3-month (e), and 9-month radiograph examinations (f)

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  Discussion Top

Follow-up of compulsory revascularization clinical cases according to the American Association of Endodontic Clinical for a Regenerative Procedure to verify clinical and radiographic success, i.e., no pain or swelling (between the first and second appointments), reduced apical radiolucency (observed 1, 3, 6, and 12 months after treatment), increased root wall width (before increasing root length and occurring 12–24 months after treatment), increased root length, and positive pulp vitality response. Success rates are also measured to the extent possible with regard to achieving the primary, secondary, and tertiary goals. The main goal is the elimination of symptoms and evidence of bone healing. The secondary objectives include increasing the wall thickness or increasing length, and the tertiary objective is a positive response to vitality testing.[18] The minimum time required to assess radiographic evidence of root development and to carry out clinical examinations is 12–18 months.[7],[16]

The apexification method using calcium hydroxide and MTA has proven to be effective due to the narrowing of the apical foramen of immature teeth. However, the advantage of pulp revascularization lies in the possibility of further root development and strengthening of the dentinal wall, thereby strengthening the roots against fractures.

The success of apical revascularization of immature teeth with apical periodontitis, according to Windley et al., depends on (1) disinfection of the canal, which is considered a key factor for successful treatment, (2) the formation of a scaffold (blood clots), and (3) sealing tightly to prevent bacterial access, including hermetic coronal filling.[14]

Several factors indicate suitability for case selection for revascularization applications other than the consideration of root canal disinfection, such as the apex diameter and the patient's age. An open apex allows the migration of mesenchymal stem cells to the root canal space, and this makes it possible for the host cell to form new tissue in the root canal space. An apical opening with a diameter of 1.1 mm or more will increase the success of regenerative endodontic treatment by 18%–34%.[19] Apical revascularization treatment is still quite effective in apices 0.3–1.1 mm in diameter, whereas in this case, the apex was open about 1.07 mm (CBCT results). Regenerative endodontic treatment procedures are generally limited to adolescent patients; most are 8–16 years old, and they are not recommended for children under 8 years or over 16 years of age.[19] In this case report, the patient was 11 years of age with minimal periapical pathology.

Cleaning of microorganisms is carried out with minimal or no instrumentation because excessive cleaning will increase the brittleness of the tooth wall and injure the stem cells in the apex wall of the tooth. Growth factors and other cells that are important for the regeneration process can also be lost due to instrumentation.[4]

Necrotic tissue is removed by slowly irrigating the root canal wall using 20 mL of 1.25% NaOCl with an irrigation needle 20G.[12],[20] When doing irrigation using NaOCl, the needle must be inserted into the root canal to a point 2 mm from the apical foramen, and the NaOCl must be slowly irrigated to prevent NaOCl entering the periapical tissue.[21] Irrigation was continued using a 10-mL 17% EDTA solution instead of chlorhexidine as the final rinsing solution. Recent studies suggest the use of EDTA as a chelating agent because it can decalcify the surface of the dentin's root canal and expose its collagen fibers. Collagen has an adhesion motif for adhesion of new cells, and decalcification of dentin releases growth factors, attracts new cells, and triggers differentiation of odontoblast-like cells.[22] EDTA is also a “sealer,” which maximizes the bacteriostatic and bactericidal effects of various agents. The chelating effect will allow the release of growth factors in dentin during dentinogenesis and stimulate the proliferation of stem cells.[23],[24] EDTA irrigation aims to remove the first layer of dentin, which has been in contact with sodium hypochlorite, which is contaminated by chlorine residues and is toxic to cells. EDTA will also release dentin intrinsic growth factors, which will then play a role in regeneration in the subsequent process.[11] Root canal system infections occur as a result of many bacterial species, and thus, a single antibiotic cannot be used to create a sterile environment. In this case of revascularization, the intracanal medication used was TAP, consisting of a mixture of ciprofloxacin, metronidazole, and tetracycline, which are used as intracanal drugs in most cases for 3–4 weeks.[12] Tetracycline causes discoloration. Therefore, Iwaya et al. used dual antibiotics containing ciprofloxacin and metronidazole.[9] A modified TAP containing ciprofloxacin, metronidazole, and cefaclor has also been suggested.[25] Anotherin vitro study conducted by Hoshino et al. showed that each antibiotic used singly is ineffective against bacteria present in the pulp, dentin, and apical lesions, while the trio of antibiotics allows complete sterilization of germs. Sato et al. developed a TAP that kills various root canal bacteria more efficiently, consisting of minocycline (Gram + and Gram − spectrum), ciprofloxacin (Gram + and Gram − spectrum), and metronidazole (spectrum of anaerobic bacteria and protozoa).[26]

Preventing coronal leakage from bacteria into cleaned and treated root canals is a major prerequisite for successful revascularization, so double coronal restoration is recommended.[4] At the second visit, a cervical barrier is needed using MTA, which is considered to have beneficial physical and biological properties.[27] A minimum of 4 mm MTA is placed in one-third of the coronal root canals to ensure a good seal, which is then restored using a composite and/or glass ionomer, ensuring a double seal.[28] Based on the case series, the following recommendations are made to help with the revascularization technique: (1) clinicians should consider the use of an anesthetic without a vasoconstrictor when trying to induce bleeding, (2) a collagen matrix is useful for the controlled placement of MTA to a desired and optimal level, (3) patients/parents should be informed about the potential for staining, especially in anterior teeth when the paste contains minocycline, and (4) patient/parent compliance with the necessary multiple appointment treatment plan may be significant for case selection.[29]

Before proceeding with the second visit, it is important to ensure that all clinical signs and symptoms have diminished. If clinical signs or symptoms persist, the procedure performed at the first visit must be repeated. If clinical signs or symptoms persist for several visits, an apexification procedure must be considered.[30] Anesthesia without vasoconstrictors must be chosen to prevent narrowing of the arteries in the apical region or limited blood flow when bleeding is mechanically induced.[31]

Apical tissues beyond the confines of the root canal need to be stimulated with a sterile endodontic file or explorer to induce bleeding into the canal space. It takes approximately 15 min for the blood to clot and stabilize below the cementoenamel junction, applying intracanal pressure with a sterile cotton pellet soaked in a sterile saline solution. If bleeding does not occur, it may be necessary to dip a file with a small bend in 17% EDTA and spread it over the instrument to prevent coagulation of the blood. If bleeding still does not occur, in a tooth with more than one root, it is possible to use a syringe to draw blood from the adjacent canals and put it in the dry ones. An alternative is to draw blood with venipuncture and inject it into the canal system.[32]

In cases of revascularization, it is necessary to verify clinical success in the 6-month posttreatment period to evaluate success and to identify treatment progress. According to Chen et al., immature teeth diagnosed with pulp necrosis and apical periodontitis can show several types of revascularization results: Type I – an increase in dentin wall width and root tip development; Type II – continued root development, which is not significantly associated with apical closure; Type III – root tip development without apical closure; Type IV – root canal calcification; and Type V – mineralized tissue barrier between the MTA cervical plug and the radicular apex.[33]

Periodic control for clinical and radiographic evaluation must be scheduled. The clinical examination must reveal no pain with palpation and percussion and no soft tissue or sinus tract swelling. Periapical radiographs must be performed to observe apical radiolucency loss, an increase in root wall width, and/or an increase in root length [Figure 6]b and [Figure 6]d. Pulp vitality tests must also be performed because some cases exhibit a positive response after treatment. If signs and symptoms persist, or if no radiographic evidence of healing and root development is found after 2 years, this indicates the failure of the procedure, and other treatments, such as calcium hydroxide or MTA apexification, must be performed. Other authors are more aggressive and suggest that a more traditional method should be used if there are no signs of regeneration within 3 months.[32]
Figure 6: Final result. Preoperative intraoral photos (a) and radiograph (b) as well as postfinal restoration with a 9-month postcontrol intraoral image (c) and radiograph (d)

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The evaluation of endodontic treatments for immature necrotic permanent teeth in this report did not use standardized novel method[34] for measuring radiographic root changes after endodontic therapy, but it was compared based on clinical and radiographic outcomes by computed tomography or periapical radiographic examination.[35] With this method, it is difficult to minimize potential differences in angulations between the preoperative and recall images and to calculate the continued development of the root length and dentin wall thickness.[7] However, the images were evaluated, observed, and analyzed by a radiology specialist dentist and the authors (five persons in total).

According to Udhya and Varadharaja, there are a few disadvantages of this procedure compared to other procedures. Long-term clinical results are not yet available, and the source of regenerated tissue has not been identified. Another disadvantage is that the revitalized tooth may be susceptible to further pulp disease and require retreatment. It is possible that the entire canal might be calcified, compromising esthetics and potentially increasing the difficulty of future endodontic procedures if required. In the event that the final restorative treatment plan involves post and core, revascularization is not the correct treatment option because the vital tissue in the apical two-thirds of the canal cannot be violated for postplacement.[36]

  Conclusion Top

Apical revascularization is a procedure that promotes thickening of the dentinal wall and closure of the apical foramen, thereby preventing teeth from becoming weak. The minimum expectation of revascularization treatment is the absence of undesirable signs and symptoms, but the ultimate goal is full regeneration of the pulp complex and ideal root development. Treatment is considered successful if all unfavorable signs and symptoms have been removed and the roots develop satisfactorily.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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