Management and outcomes of apexification procedures in traumatized immature teeth

The oral health of pediatric patients is a significant concern, with dental injuries being a common occurrence in this vulnerable population. Traumatic injuries to immature teeth, characterized by incomplete root development and open apices, present unique challenges that require specialized clinical management. Understanding the anatomy and developmental characteristics of immature teeth is crucial for effective management. Historically, apexification procedures relied on calcium hydroxide, but advancements in dental pulp biology led to regenerative endodontics, a transformative approach that preserves pulp vitality while promoting apical closure. Contemporary techniques include calcium hydroxide apexification, mineral trioxide aggregate (MTA) apexification, and regenerative endodontics, each with its advantages and considerations. Patient selection, radiographic assessment, choice of biocompatible materials, and post-operative care are key components of contemporary apexification protocols. Advanced imaging modalities like cone-beam computed tomography (CBCT) enhance diagnostic accuracy. Challenges in apexification procedures include infection control, the risk of root fractures, and dealing with resorption phenomena. Moreover, pediatric patients require special attention to address compliance and psychological factors. The long-term outcomes of apexification procedures extend beyond clinical and radiographic parameters and encompass growth and development as well as the quality of life of pediatric patients. Preservation of arch integrity, prevention of malocclusion, and maintaining oral health-related quality of life are vital considerations.

Ignorance: the root of misfortune. Early childhood dental trauma to upper central incisor- consequences and its management-a case report

The successful treatment of early childhood dental trauma is influenced by the child’s age, the child’s cooperation, and the time-lapse between the trauma and seeking dental care. Delayed emergency care raises the risk of complications, making vital tooth survival and/or a favourable prognosis less predictable. As a result, prompt treatment and follow-up are critical to reducing the risk of both short and long-term negative outcomes. This case report describes an early childhood trauma to the upper central incisor which was left untreated. It subsequently developed discoloration, pulpal necrosis, thin dentinal walls, and a wide-open apex. An absorbable collagen barrier was placed against which MTA was condensed and filled up to the cementoenamel junction. A subsequent assessment revealed clinical and radiographic success.

A segmental root development as an unusual healing response to the revitalization of mandibular second premolar

A 15-year-old patient reported persistent pain in the left mandibular second premolar (#35) following a traumatic bite 3 months ago. Clinical examination revealed a fractured central cusp suggestive of dens evaginatus. Intraoral periapical radiograph revealed an immature permanent tooth with a periapical radiolucency. A diagnosis of pulp necrosis with symptomatic apical periodontitis was made. The tooth was treated according to the revised guidelines of regenerative endodontic procedure by the American Association of Endodontics. The follow-up evaluation revealed a complete resolution of periapical pathology. A detached radiopaque tissue was appreciated at the 12-month follow-up. It resembled a broken root tip at the 24-month follow-up. Both the main root body and disjointed root tip developed independently. A cone-beam computed tomography evaluation at the 36-month follow-up confirmed the segmented development of the apical root tip.

Fracture resistance of simulated immature teeth reinforced with different mineral aggregate-based materials

Abstract This study assessed the fracture resistance of simulated immature teeth reinforced with calcium aluminate cement (CAC) or mineral trioxide aggregate (MTA) containing calcium carbonate nanoparticles (nano-CaCO3). The microstructural arrangement of the cements and their chemical constitution were also evaluated. Forty-eight canines simulating immature teeth were distributed into 6 groups (n=8): Negative control - no apical plug or root canal filling; CAC - apical plug with CAC; CAC/nano-CaCO3 - apical plug with CAC+5% nano-CaCO3; MTA - apical plug with MTA; MTA/nano-CaCO3 - apical plug with MTA+5% nano-CaCO3; and Positive control - root canal filling with MTA. The fracture resistance was evaluated in a universal testing machine. Samples of the cements were analyzed under Scanning Electron Microscope (SEM) to determine their microstructural arrangement. Chemical analysis of the cements was performed by Energy Dispersive X-ray Spectroscopy (EDS). The fracture resistance of CAC/nano-CaCO3 was significantly higher than the negative control (p<0.05). There was no significant difference among the other groups (p>0.05). Both cements had a more regular microstructure with the addition of nano-CaCO3. MTA samples had more calcium available in soluble forms than CAC. The addition of nano-CaCO3 to CAC increased the fracture resistance of teeth in comparison with the non-reinforced teeth. The microstructure of both cements containing nano-CaCO3 was similar, with a more homogeneous distribution of lamellar- and prismatic-shaped crystals. MTA had more calcium available in soluble forms than CAC.

Resumo Este estudo avaliou a resistência à fratura de dentes imaturos simulados reforçados com cimento de aluminato de cálcio (CAC) ou trióxido agregado mineral (MTA) contendo nanopartículas de carbonato de cálcio (nano-CaCO3). O arranjo microestrutural dos cimentos e sua constituição química também foram avaliados. Quarenta e oito caninos simulando dentes imaturos foram distribuídos em 6 grupos (n=8): Controle negativo - sem plug apical ou obturação do canal radicular; CAC - plug apical com CAC; CAC/nano-CaCO3 - plug apical com CAC + 5% nano-CaCO3; MTA - plug apical com MTA; MTA/nano-CaCO3 - plug apical com MTA + 5% nano-CaCO3; e Controle positivo - obturação dos canais radiculares com MTA. A resistência à fratura foi avaliada em máquina universal de ensaios. Amostras dos cimentos foram analisadas em Microscópio Eletrônico de Varredura (MEV) para determinar seu arranjo microestrutural. A análise química dos cimentos foi realizada por Espectroscopia de Energia Dispersiva de Raio-X (EDS). A resistência à fratura de CAC/nano-CaCO3 foi significativamente maior do que o controle negativo (p<0,05). Não houve diferença significativa entre os outros grupos (p>0,05). Ambos os cimentos apresentaram microestrutura mais regular com a adição de nano-CaCO3. As amostras de MTA apresentaram mais cálcio disponível em formas solúveis do que CAC. A adição de nano-CaCO3 ao CAC aumentou a resistência à fratura dos dentes em comparação aos dentes não reforçados. A microestrutura de ambos os cimentos contendo nano-CaCO3 foi semelhante, com uma distribuição mais homogênea de cristais de formato lamelar e prismático. MTA apresentou mais cálcio disponível nas formas solúveis do que CAC.

Effect of orthodontic forces on root length of immature mandibular second premolars: a split-mouth randomized clinical trial

ABSTRACT Objective: To assess the effect of orthodontic forces on changes in root length of immature mandibular second premolars. Methods: Sixty-four mandibular second premolars (MSP) with immature apices (left and right sides) of 32 patients aged between 10 and 13 years were evaluated. Orthodontic treatment was started after obtaining periapical radiographs (T1) from the MSPs of each patient. Brackets were bonded, except the ones of MSPs (left or right by random as control MSP, and the other side as test MSP). After 9-12 months, a second periapical radiograph (T2) was obtained from the MSPs of each patient. Then, brackets were bonded to the control MSPs, which were not bonded before. After 18 ± 3 months, a third periapical radiograph (T3) was obtained. Changes in root length were evaluated by using a new formula. The test and control MSPs at T1, T2 and T3 were compared using repeated measures ANOVA and parametric tests. P-value smaller than 0.05 was statistically significant. Results: There was no significant difference between the test and control groups in the mean root length of MSP at T1 (p= 0.48) and T3 (p= 0.078). The root length at T2 (p= 0.001) was significantly different between test and control MSPs, and the test group showed longer root length than the control group. Conclusions: Orthodontic force applied for leveling and alignment of immature MSPs may not have destructive effects on the roots, and may accelerates root formation in short-term. Normal root length was achieved at the end of root development.

RESUMO Objetivo: Avaliar o efeito das forças ortodônticas nas mudanças do comprimento radicular de segundos pré-molares inferiores com raízes incompletas. Métodos: Foram avaliados 64 segundos pré-molares inferiores (SPI) com raízes incompletas (lados direito e esquerdo da mandíbula) de 32 pacientes com idades entre 10 e 13 anos. O tratamento ortodôntico teve início após a obtenção de radiografias periapicais (T1) dos SPIs de cada paciente. Foram colados braquetes em todos os dentes, com exceção dos SPIs (do lado esquerdo ou direito, de forma aleatória, como grupo controle; e o SPI contralateral como grupo teste). Após 9 a 12 meses, uma segunda radiografia periapical (T2) foi obtida dos SPIs de cada paciente. Então, braquetes foram colados nos SPIs do grupo controle, que não haviam sido colados anteriormente. Após 18 ± 3 meses, uma terceira radiografia periapical (T3) foi obtida. As mudanças no comprimento radicular foram avaliadas por meio de uma nova fórmula. Os SPIs teste e controle foram comparados em T1, T2 e T3 usando ANOVA para medidas repetidas e testes paramétricos. Valores de p< 0,05 foram considerados estatisticamente significativos. Resultados: Não foi encontrada diferença significativa no comprimento radicular médio dos SPIs entre os grupos teste e controle em T1 (p= 0,48) e T3(p= 0,078). O comprimento radicular dos SPIs em T2 (p= 0,001) foi significativamente diferente entre os lados teste e controle, sendo que o grupo teste apresentou maior comprimento radicular do que o grupo controle. Conclusões: As forças ortodônticas aplicadas para o alinhamento e nivelamento de SPIs com raízes incompletas podem não ter efeitos danosos nas raízes, podendo, inclusive, acelerar a formação radicular em curto prazo. O comprimento radicular normal foi alcançado ao fim da formação radicular.

The ability of platelet-rich plasma to regenerate a non-vital immature permanent teeth / Capacidade do plasma rico em plaquetas de regenerar dentes permanentes imaturos não vitais

Objective: To test the ability of platelet-rich plasma clinically and radiologically for pulp regeneration of immature teeth with apical periodontitis. Material and Methods: An experimental study was conducted From (March/2018-July/2020) 12 upper central immature incisors with acute apical periodontitis and necrotic pulp from six patients receiving regenerative endodontic treatment using concentrated platelets rich plasma were performed by the same endodontist at Mediclinic Middle East Hospitals. Informed consent, including explanation of risks and alternative treatments or no treatment were prepared and filled by the patient parents. The therapeutic protocol was involved accessing the pulp chamber; irrigation copiously with sodium hypochlorite; applying calcium hydroxide as intracanal medicament and a provisionally sealing it after 4 weeks. The canal was cleaned, dried and injected with concentrated platelets rich plasma which serve as a scaffold for pulp regeneration. MTA was used to seal the chamber before final filling with composite. Evaluations: All teeth were monitored clinically (mobility, palpation, percussion, and sensitivity cold test) and radiographically. Results: Twenty months follow-up all teeth showed resolution of periapical radiolucencies, continued root development with positive response to sensitivity cold test and no discoloration. Conclusion: The results of this study confirmed the previous finding that pulp regeneration can be gained by using cPRP successfully. (AU)

Objetivo: Testar a capacidade do plasma rico em plaquetas clinicamente e radiograficamente para a regeneração pulpar em dentes imaturos com periodontite apical. Material e Métodos: O estudo experimental foi realizado em Março/2018 e Julho/2020, 12 incisivos centrais imaturos com periodontite apical aguda e necrose pulpar em 6 pacientes recebendo tratamento endodôntico regenerativo usando concentrado de plasma ricas em plaquetas. Foram realizadas pelo mesmo endodontista no Hospital Mediclinic Middle East. O consentimento informado incluindo explicação do risco e tratamentos alternativos ou de nenhum tratamento foi preenchido pelos responsáveis do paciente. O protocolo terapêutico envolveu acesso à câmara pulpar, irrigação abundante com hipoclorito de sódio, aplicação de hidróxido de cálcio como medicação intracanal e selado intracanal por 4 semanas. O canal foi limpo, seco e injetado concentrado de plasma rico em plaquetas que servem como um scaffold para a regeneração pulpar. Usou-se MTA para selar a câmara antes do preenchimento final com compósitos. Avaliações: Todos os dentes foram monitorados clinicamente (mobilidade, palpação, percussão e teste de sensibilidade com frio) e radiograficamente. Resultados: Após 20 meses de acompanhamento, todos os dentes apresentaram a resolução das radioluscências periapicais, desenvolvimento contínuo da raiz com resposta positiva ao teste de sensibilidade ao frio e sem descoloração. Conclusão: O resultado do estudo confirmou descobertas anteriores que a regeneração pulpar pode ser obtida usando cPRP com sucesso. (AU)

Regenerative Endodontics – Looking Inward

Regenerative endodontics has become a revolutionizing tissue engineering concept in the treatment of immature permanent teeth for over two decades. It has been described as a ‘paradigm shift’ in the treatment of immature teeth, since it fosters continued root maturation. An immature necrotic permanent tooth is usually a result of trauma or infection due to which the tooth becomes non-vital before completing root development. In such cases, the root walls are left thin and weak with an open apex. Traditional apexification procedures may resolve pathology but have not been able to prove tooth survival due to absence of continued root development and risk of root fracture. A successful regenerative endodontic procedure (REP) results in resolution of signs and symptoms of pathology, radiographic signs of healing, proof of continued root development as well as presence of pulp vitality due to the regeneration of pulp tissue in the root canal. Various stem cells, growth factors, scaffolds and suitable environment form the tetrad of elements necessary to induce regeneration of dental pulp. While there has been some success in isolating dental pulp cells with in-vitroexperiments, it has been proven to be rather difficultto implement the same in a practical perspective ex vivo. Although there has been clinical success related to REP, histologically they seem to undergo guided endodontic repair rather than true regeneration of physiologic pulp tissue. This review provides an overview of components of tissue engineering, clinical protocol and predictable outcomes for REP and recent advances in regenerative dentistry.

Negative pressure irrigation presents mineralizing potential in dogs' immature teeth with periapical lesion

Abstract The objective of this in vivo study was to assess the effect of the root canal irrigation by negative and positive apical pressure on the expression of molecules that are an indicative of cell differentiation with mineralizing phenotype in teeth of dogs with incomplete rhizogenesis and induced periapical lesion. A total of 30 teeth (60 roots) were distributed into 3 groups (n=20): EndoVac®, Conventional and Control. After 90 days, the routine histotechnical procedures were performed and the sections were submitted to immunohistochemical technique for the staining of osteopontin (OPN), alkaline phosphatase (ALP) and the RUNX2 transcription factor in the apical and periapical regions of the roots. A semi-quantitative analysis of the positive immunostaining was performed and the intensity of the expression was classified in absent (0), mild (1), moderate (2), or intense (3). Scores data were statistically analyzed by the Kruskal-Wallis non-parametric test and Dunn post-test, and the significance level was set at 5%. RUNX2 immunostaining revealed that in the negative pressure group there was a significantly stronger (p<0.05) immunostaining in comparison to the control group. Regarding the OPN expression, it was not possible to detect a statistically significant difference between the groups (p>0.05). After analyzing ALP immunostaining, a statistically significant difference was observed between the groups (p<0.05), and the negative pressure group showed a markedly stronger mark immunostaining than the control group. The results of the present in vivo study allowed concluding that negative apical pressure irrigation presents mineralizing potential in immature teeth with apical periodontitis.

Resumo O objetivo do presente estudo in vivo foi avaliar o efeito da irrigação do canal radicular por pressão apical negativa e por pressão positiva na expressão de moléculas que são indicativas de diferenciação celular com fenótipo mineralizador em dentes de cães com rizogênese incompleta e lesão periapical. Um total de 30 dentes (60 raízes) foi distribuído em 3 grupos (n=20): EndoVac, Convencional e Controle. Após 30 dias, foram realizados os procedimentos histotécnicos de rotina e os cortes foram submetidos à técnica de imunohistoquímica para marcação de Osteopontina (OPN), Fosfatase Alcalina (ALP) e para o fator de transcrição RUNX2 nas regiões apical e periapical das raízes. Foi realizada uma análise semi-quantitativa da imunomarcação positiva e a intensidade da expressão foi classificada em ausente (0), leve (1), moderada (2) ou intensa (3). Os dados por escores foram analisados estatisticamente pelo teste não-paramétrico de Kruskal-Wallis e pelo pós-teste de Dunn, e o nível de significância adotado foi de 5%. A imunumarcação para RUNX2 revelou que no grupo pessão negativa houve marcação significativamente mais intensa (p<0,05), em comparação ao grupo controle. Com relação à expressão de OPN, não foi possível observer diferença estatisticamente significante entre os grupos (p>0,05). Após análise da imunomarcação para ALP, foi observado diferença estatisticamente significante entre os grupos (p<0,05), e o grupo pressão negativa demonstrou uma marcação siginificativamente mais intensa do que o grupo controle. Os resultados do presente estudo in vivo permitiram concluir que a irrigação por pressão apical negativa apresenta potencial mineralizador em dentes com ápice aberto e lesão periapical.

Apical Negative Pressure irrigation presents tissue compatibility in immature teeth

Abstract Aim: To compare the apical negative pressure irrigation (ANP) with conventional irrigation in the teeth of immature dogs with apical periodontitis. Methods: Fifty-two immature pre-molar root canals were randomly assigned into 4 groups: ANP (n=15); conventional irrigation (n=17); healthy teeth (control) (n = 10); and teeth with untreated apical periodontitis (control) (n=10). After induction of apical periodontitis, teeth were instrumented using EndoVac® (apical negative pressure irrigation) or conventional irrigation. The animals were euthanized after 90 days. The sections were stained by HE and analyzed under conventional and fluorescence microscopy. TRAP histoenzymology was also performed. Statistical analyses were performed with the significance level set at 5%. Results: There was difference in the histopathological parameters between ANP and conventional groups (p<0.05). The ANP group showed a predominance of low magnitude inflammatory infiltrate, a smaller periodontal ligament, and lower mineralized tissue resorption. There were no differences in the periapical lesion extensions between the ANP and conventional groups (p>0.05). However, a lower number of osteoclasts was observed in the ANP group (p<0.05). Conclusion: The EndoVac® irrigation system presented better biological results and more advanced repair process in immature teeth with apical periodontitis than the conventional irrigation system, confirming the hypothesis.

Fracture Resistance of Simulated Immature Teeth after Different Intra-radicular Treatments

The aim of this study was to evaluate the fracture resistance of simulated immature teeth after different intra-radicular treatments. Crowns and roots of bovine incisors were cut transversally and removed to simulate immature teeth. Root canal preparation and flaring were performed using a bur in crown-apex and apex-crown direction. The samples were distributed into 5 groups (n=10): Positive control (PoC) - no root canal flaring or filling; Negative control (NeC) - teeth were sectioned and their root canals were flared; Direct anatomical glass fiber post (RaP) - #2 Reforpost main glass fiber post relined with composite resin; Double tapered conical glass fiber posts (ExP) - #3 Exacto glass fiber post; and #2 Reforpost main glass fiber + Reforpin accessory glass fiber posts (RrP). In RaP, ExP and RrP, 4.0-mm apical plugs were done with MTA Angelus. The specimens were embedded in polystyrene resin inside cylinders and the periodontal ligament was simulated with a polyether-based impression material. The specimens were submitted to compressive fracture strength test (0.5 mm/min at 135° relative to the long axis of the tooth) in a servo-hydraulic mechanical testing machine MTS 810. Data were subjected to one-way ANOVA and Dunnett's C or Tukey's tests (α=0.05). The control groups (PoC and NeC) showed lower fracture strength than the experimental groups. NeC presented the lowest resistance and ExP presented the highest resistance among the experimental groups. The flaring procedures produced a detrimental effect on the fracture resistance of the bovine teeth. Glass fiber intra-radicular posts increased significantly the fracture resistance of simulated immature teeth.

O objetivo deste estudo foi avaliar a resistência à fratura de dentes com rizogênese incompleta simulada após diferentes tratamentos intra-radiculares. A rizogênese incompleta foi simulada pelo seccionamento das coroas e raízes de incisivos bovinos. O preparo e alargamento do canal radicular foram realizados utilizando uma broca no sentido coroa-ápice e ápice-coroa. As amostras foram distribuídas (n=10) em cinco grupos: controle positivo (PoC) - sem preparo do canal radicular e sem obturação; controle negativo (NeC) - os dentes foram seccionados e os canais radiculares foram preparados; pino anatômico direto Reforpost #2 (RaP) - pino de fibra de vidro principal + resina composta; pino de fibra de vidro com dupla conicidade (ExP) - pino de fibra de vidro Exacto #3; e pino de fibra de vidro Reforpost #2 + pinos de fibra de vidro acessórios Reforpin (RrP). Nos grupos RaP, ExP e RrP foram realizados plugs apicais de MTA Angelus com 4,0 mm. As amostras foram incluídas em cilindros com resina de poliestireno e o ligamento periodontal foi simulado com material de moldagem à base de poliéter. As amostras foram submetidas ao teste de resistência à fratura, por meio de força compressiva (0,5 mm/min a 135º em relação ao longo eixo do dente) em uma máquina de ensaios mecânicos MTS 810. Os dados foram submetidos à ANOVA a um critério e aos testes para comparações múltiplas Dunnett C ou Tukey HSD (α=0,05). Os grupos controle (PoC e NeC) apresentaram resistência à fratura inferior aos grupos experimentais, sendo o menor valor médio produzido por NeC. ExP produziu os maiores valores de resistência à fratura entre os grupos experimentais. Os procedimentos de preparo e alargamento produziram efeitos prejudiciais na resistência à fratura de dentes bovinos. A utilização de pinos de fibra de vidro intra-radiculares aumentou significativamente a resistência à fratura de dentes com rizogênese incompleta simulada.

Treatment of non-vital immature teeth with amoxicillin-containing triple antibiotic paste resulting in apexification

A recent treatment option for non-vital immature teeth in young patients is revascularization with triple antibiotic paste (TAP). However, tooth discoloration was reported with the use of conventional minocycline-containing TAP. In this case report, amoxicillin-containing TAP was used for revascularization of non-vital immature teeth to prevent tooth discoloration. At the 1 yr follow up, the teeth were asymptomatic on clinical examination and showed slight discoloration of the crown due to mineral trioxide aggregate (MTA) filling rather than amoxicillin-containing TAP. Radiographic examination revealed complete resolution of the periapical radiolucency, and closed apex with obvious periodontal ligament space. However, the root growth was limited, and the treatment outcome was more like apexification rather than revascularization. These results may be due to unstable blood clot formation which could not resist the condensation force of MTA filling, whether or not a collagen matrix was in place. These cases showed that although revascularization was not successful, apexification could be expected, resulting in the resolution of the periapical radiolucency and the closure of the apex. Therefore, it is worthwhile attempting revascularization of non-vital immature teeth in young patients.