Apexogenesis of an Immature Permanent Molar with Irreversible Pulpitis Using Mineral Trioxide Aggregate Pulpotomy: A Case Report.

Carious exposure of an irreversibly inflamed vital pulp in a young permanent tooth presents a significant clinical challenge to clinicians to maintain the vitality. Direct pulp capping, partial pulpotomy, and complete pulpotomy are the available procedures to treat young permanent tooth. Mineral trioxide aggregate and biodentine are currently the material of choice for these procedures. The present case report describes the successful apexogenesis of mandibular left first permanent molar using mineral trioxide aggregate. The 18-month follow-up of the case demonstrated clinical and radiographic success with absence of any signs and symptoms and continued root formation.

Open Apex and its Management: Review Article.

During root development, the teeth are subjected to a variety of assaults. Due to this, the root stops forming and the closure of the apex does not take place. Root canal treatment becomes a major challenge in these cases because of the width of the canal and wide-open apices. Management of open apices includes apexogenesis in vital young permanent teeth and apexification, which is a method to induce a calcified barrier in the root. Newer concepts include regeneration and revascularization procedures, which still need to be experimented with further.

CLINICAL-THERAPEUTICAL MANAGEMENT OF EXPOSED PULP USING BIOACTIVE MATERIALS: TWO CASE REPORTS

Aims: This article present alternatives of bioactive materials use for direct pulp capping in immature teeth and for apexogenesis.Case report: Two case reports with the application of bioactive cementsare presented here: one in a tooth with pulp exposure and another with deep carious lesion, pulp exposure and open apex.Results: In both cases, the treatment was performed in one visit and a favorable clinical and radiographic follow-up was achieved.Conclusion: The use of bioactive materials ledto the formation of a dentin bridge and healing process in the pulp tissue exposure, without the need for conventional endodontic treatment

Mineral Trioxide Aggregate Apexogenesis: A Systematic Review.

Objectives: To evaluate the clinical and radiographic outcomes of apexogenesis with mineral trioxide aggregate (MTA) against other pulpotomy agents in carious/traumatized immature permanent teeth. Data Source: A web-based search for possibly relevant scientific papers in the English language between January 2013 and August 2022 was undertaken in the databases such as PubMed, Scopus, Cochrane Library, and EMBASE. Only randomized clinical trials that compared MTA against other pulpotomy medicaments conducted in vital immature permanent dentition with open apex, having a sample size of not less than 20 with at least 6 months follow-up, reporting clinical or radiographic outcomes were included in the current review. Case studies, case series, animal studies, in vitro studies, non-clinical/clinical trials on mature/necrotic permanent or primary dentition, systematic reviews, and letters to the editor were excluded. Study Selection: A total of 236 articles were retrieved from the databases during the search procedure. Two independent investigators conducted a full-text review of 83 studies following a screening of titles and abstracts. Eventually, seven studies were considered for the review. The Cochrane bias assessment tool was used to evaluate the quality of included studies. Five of the selected studies were assigned a low evidence level, whereas two were rated a high evidence level. Conclusion: The present review indicated that the diverse pulpotomy agents had comparable clinical outcomes with MTA for apexogenesis in traumatized or carious immature permanent teeth. However, there is a lack of substantial information to draw firm conclusions about the benefits of one material over another.

Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth.

This review guidance is a work in progress because the limitations of regenerative endodontics are still being discovered. The endodontic treatments for immature permanent teeth with a necrotic pulp can vary considerably among endodontic practitioners. Whereas, regenerative endodontic treatments are growing in popularity and are creating ever more complex treatment protocols, involving revascularization and/or autologous platelet-rich plasma and scaffolds to elicit host stem cell de novo tissue formation to reestablish the vitality of immature teeth for the purpose of continuing root maturation. Despite much evolving controversy about their potential benefits, risks, prognosis, and contraindications, this review is aimed to discuss how to ensure that regenerative endodontic treatments are successful, by strictly adhering to case selection criteria, and following precise steps to accomplish and monitor the success of the treatment. A review of the endodontic literature was performed, together with practical observations of the problems and outcomes of performing regenerative endodontic treatments. Traditionally, apexification has long been the treatment of choice provided to immature teeth with a necrotic pulp. Regenerative endodontics may be provided as an alternative to apexification, if the tooth and patient meet all the case selection criteria, and if there are no contraindications. Regenerative endodontics has the unique potential advantage of being able to continue the root development in immature permanent teeth, thereby potentially saving the teeth for the lifetime of the patient. Whereas, conventional endodontic root canal treatment, Cvek partial pulpotomy, apexogenesis, and apexification, should always be provided when these treatments are more likely to benefit the patient because they can be more successful than regenerative endodontics.

Evaluation of the Treatment Protocols in the Management of Pulpally Involved Young Permanent Teeth in Children: A Systematic Review and Meta-analysis.

Background: In children with young permanent teeth, dental caries and traumatic injuries are the most common problems leading to pulp necrosis. Since, root development is completed in two to three years after eruption of the tooth into the oral cavity, loss of pulp vitality in young permanent tooth creates distinctive problems. In spite of exceeding availability of treatment procedures there is a need to search for a substantial procedure to treat young permanent teeth effectively. Aim: The aim of this systematic review was to evaluate the treatment protocols in the management of pulpally involved young permanent teeth in children. Method: Systematic search was conducted on databases PubMed, Cochrane, and Google Scholar among studies published from 1st January 2010 till 31st May 2020. Studies meeting the inclusion criteria were included in the review and were then assessed for quality with the help of predetermined criteria which categorized studies into high, medium, and low. Results: Search strategy yielded 4,846 articles. After screening through titles and abstracts, 33 articles remained which were further screened for full text. At the end, 14 articles were included in systematic review. Furthermore, the included articles were statistically evaluated by meta-analysis. Conclusion: In apexogenesis and apexification procedures, newer biomimetic materials like mineral trioxide aggregate and biodentine have more success rate than conventionally used calcium hydroxide. Among regenerative endodontic procedures platelet-rich plasma and platelet- rich fibrin showed better results. Clinical significance: To amend clinician perceptions towards acceptance of the newer regenerative procedures and their effectiveness in management of young permanent tooth. How to cite this article: Saxena N, Hugar SM, Soneta SP, et al. Evaluation of the Treatment Protocols in the Management of Pulpally Involved Young Permanent Teeth in Children: A Systematic Review and Meta-analysis. Int J Clin Pediatr Dent 2022;15(S-1):S103-S113.

Comparative Evaluation of Platelet-rich Fibrin and Concentrated Growth Factor as Scaffolds in Regenerative Endodontic Procedure: A Randomized Controlled Clinical Trial.

AIM: This randomized controlled trial evaluated the efficacy of platelet-rich fibrin (PRF) and concentrated growth factor (CGF) as scaffolds in the regenerative endodontic procedure (REP) using clinical and radiographic parameters along with cone-beam computed tomographic (CBCT) analysis. MATERIALS AND METHODS: The apexogenesis procedure was performed in 16 teeth. They were randomly divided into two groups of eight teeth each: group I and group II. In group I PRF was used as the scaffold and in group II CGF was used as the scaffold. They were evaluated for pain, pulpal vitality, tenderness on percussion, and mobility, and also evaluated using digital radiographs at 3, 6, 12, and 18 months interval. The response of the teeth was graded using Chen and Chen criteria. Increase in root length, reduction in the apical foramen dimension, and reduction in periapical lesion volume were evaluated using CBCT scans taken preoperatively and at 18 months. RESULTS: At the end of 3 months, 50% of teeth without periapical pathology were found to be vital in both groups. At the end of 18 months, 60% of the teeth in both groups showed increase in root length, all teeth showed closure of apical foramen, and reduction in the volume of periapical lesion. However, there was no statistically significant difference between the groups (p < 0.05). CONCLUSION: The clinical and radiographic features reported in this study revealed that both PRF and CGF act as effective scaffolds in REP for regeneration of pulp-dentin complex with promising results. CLINICAL SIGNIFICANCE: Apexogenesis by revascularization has not been used regularly for the treatment of nonvital teeth with open apex because the results are not reliable. Since platelet concentrates like PRF and CGF are rich in growth factors; when apexogenesis is performed by REP using these platelet concentrates, desirable results can be achieved in a short duration of time. They also accelerate the healing of periapical lesions present in such cases. With the increased success rate of apexogenesis with REP, many clinicians would prefer to use REPs as a treatment option for teeth with open apex.

Evaluation of the outcome of apexogenesis in traumatised anterior and carious posterior teeth using mineral trioxide aggregate: a 5-year retrospective study.

The purpose of this study was to evaluate the outcome of apexogenesis with mineral trioxide aggregate (MTA) in traumatised anterior and carious posterior teeth over 5 years. A comprehensive chart review was performed to obtain a retrospective of sequential previously completed cases with recalls. Clinical and radiographic data were collected for 97 vital immature teeth (40 traumatised anterior and 57 carious posterior teeth) pulpotomised (partial or full pulpotomy) using MTA with an average follow-up time of 5 years. Chi-squared test and Fisher's exact test were implemented to analyse data. The success rate in anterior teeth and posterior teeth was 82.5% and 96.4% respectively. Crown discolouration was observed in 25 (62.5%) anterior teeth. There was a significant difference between the number of successful and unsuccessful cases (P < 0.05) and there was no correlation between type of treatment and success/failure (P > 0.05). The success rate of apexogenesis using MTA in immature teeth was relatively high.

Vital pulp therapy following pulpotomy in immature first permanent molars with deep caries using novel fast-setting calcium silicate cement: A retrospective clinical study.

OBJECTIVES: To compare the success rate of vital pulp therapy following complete pulpotomy in immature first permanent molars, during caries treatment, using novel fast-setting calcium silicate cement (Novel CSC) versus MTA. METHODS: Six- to eight- years old children, who received pulpotomy of first immature permanent molar using one layer novel CSC (Protooth) or two layers slow-setting MTA (MTA Angelus) covered with glass ionomer were recalled for radiographic and clinical evaluation after two years. The effects of cement type, age, gender, jaw, anesthesia type, and restoration type were assessed on the clinical success of pulpotomy and continued root formation (apexogenesis) as the treatment outcome. RESULTS: Out of 366 included teeth in the study, 316 teeth were available for statistical analysis. The mean observation time was 28.2 ±â€¯2.7 months. Novel CSC showed significantly higher clinical success rate (93.1%) compared to MTA (84.5%). Restored teeth with stainless steel crowns after pulpotomy and treatments performed under general anesthesia had a statistically significant effect on treatment outcome in contrast to age, gender, and jaw type. CONCLUSION: The observations of this retrospective study suggested that the success rate of vital pulp therapy following complete pulpotomy using one layer fast-setting novel CSC was significantly higher than slow-setting MTA covered with glass ionomer. Treatment under general anesthesia and restoration using stainless steel crowns influenced the treatment outcome. CLINICAL SIGNIFICANCE: Novel fast-setting calcium silicate cement is a promising new biomaterial for vital pulp therapy in immature permanent molars that allows complete root formation overtime with apexogenesis. Clinicians must also be aware of the importance of immediate definitive restoration and proper sealing and isolation in vital pulp therapy.

Successful revascularization procedure in an immature permanent necrotic second lower molar: a case report with 4. 5- years follow- up

Background: Infection control is mandatory for revascularization procedures, enabling to eliminate patient's clinical symptoms and signs. Despite presenting a complex morphology when compared to anterior teeth, if a strict disinfection protocol is adopted and the revascularization procedure's biological principles are followed, the therapy can be successful in molar teeth. Methods: This case report aims to present a clinical case of successful revascularization in an immature permanent necrotic second lower molar. Clinical decisions and explanations regarding possible mechanisms related to the treatment's success in a tooth with complex morphology are discussed. Results: Revascularization procedures were performed on a 12-year-old male patient diagnosed with symptomatic periapical periodontitis in a tooth 37. The case highlights the need for infection control and biological principles that surrounds the success of this therapy. Follow-up times presented in this case were six months, 1, 2, 4 and 4.5-years, respectively. Continued root development was observed, and the tooth remains intact and without symptoms. Conclusion: The association of infection control and the biological principles of revascularization procedures allow the maintenance and continuation of tooth development, even when these present complex morphologies.

Conceptual Model for Using Imidazoline Derivative Solutions in Pulpal Management.

Alpha-adrenergic agonists, such as the Imidazoline derivatives (ImDs) of oxymetazoline and xylometazoline, are highly effective hemostatic agents. ImDs have not been widely used in dentistry but their use in medicine, specifically in ophthalmology and otolaryngology, warrants consideration for pulpal hemostasis. This review presents dental healthcare professionals with an overview of ImDs in medicine. ImD solutions have the potential to be more effective and biocompatible than existing topical hemostatic compounds in pulpal management. Through a comprehensive analysis of the pharmacology of ImDs and the microphysiology of hemostasis regulation in oral tissues, a conceptual model of pulpal management by ImD solutions is presented.

Induction of root development and apical closure in permanent mandibular molar with irreversible pulpitis through total pulpotomy with application of mineral trioxide aggregate / Inducción del termino de desarrollo radicular y cierre apical en molar mandibular permanente con pulpitis irreversible a través de pulpotomía total con aplicación de agregado de trióxido mineral

Loss of teeth vitality when root formation is incomplete, results in weaker structures leaving them prone to fractures and unfavourable long-term prognosis. Apexogenesis is currently the treatment of choice in immature teeth and is indicated in vital teeth without pulpal pathologies. The treatment aims to eliminate the causal agent of the damage, and provide the necessary conditions to preserve vitality in the tooth and induce apical root closure. A 6-year-old male patient was treated at the Endodontics Clinic, Universidad de La Frontera upon complaining of acute pain in tooth 30. The tooth presented incomplete root development due to dental caries with pulp exposure and a diagnosis of irreversible symptomatic pulpitis. Total pulpotomy was performed with the application of Mineral Trioxide Aggregate and controlled at 1, 4, 6, 7 and 12 months, achieving root development and apical closure in the permanent molar. The result was comparable with studies that support this therapy in teeth with irreversible pulpitis. This work seeks to contribute to the existing evidence on the management of immature permanent teeth with irreversible pulpitis to induce root development and apical closure, and maintain pulp vitality.

La pérdida de vitalidad en dientes con formación radicular incompleta trae como resultado el debilitamiento de estos, dejándolos propensos a fracturas con un desfavorable pronóstico a largo plazo. Las terapéuticas actuales de regeneración pulpar en dientes inmaduros estan principalmente indicadas en cuadros de pulpitis irreversible y buscan eliminar el agente causal de daño y brindarle al diente las condiciones y estímulos necesarios para preservar vitalidad e inducir el cierre apical radicular. Un paciente de 6 años de edad y de sexo masculino, acude a la Clínica de Especialidad de Endodoncia de la Universidad de la Frontera, consultando por un dolor agudo en diente 4.6 el cual presentaba un desarrollo radicular incompleto producto de una caries con exposición pulpar con diagnóstico de Pulpitis Irreversible Sintomática. Se realiza una pulpotomia total con aplicación de Mineral Trioxide Aggregate y se controla a los 1, 4, 6 y 7 meses obteniendo un interesante resultado comparable con estudios que avalan dicha terapeutica en dientes con pulpitis irreversible. Este trabajo busca contribuir a la evidencia existente sobre el manejo de dientes permanentes inmaduros con cuadros de pulpitis irreversible para inducir el desarrollo radicular, cierre apical y mantener vitalidad pulpar.

Combined effects of calcium hydroxide and photobiomodulation therapy on apexogenesis of immature permanent teeth in dogs.

Treatment of high-risk traumatic immature teeth due to incomplete root development is challenging. Apexogenesis is currently the ideal treatment option that allows normal root development. The purpose of this study was to evaluate the apexogenesis process of immature permanent teeth of dogs when co-administered with calcium hydroxide and photobiomodulation therapy (PBMT). A total of 36 immature permanent anterior and premolar teeth were selected from three 4-6-month-old dogs of Iranian mixed generation. The teeth were categorized into two groups, calcium hydroxide with laser irradiation (CHL) and calcium hydroxide without laser irradiation (CH). All the selected teeth received calcium hydroxide pulpotomy. After restoring teeth with amalgam, the CHL group received gallium­aluminum-arsenide (GaAlAs) diode laser (810 nm, 4.2 J/cm2, 0.3 W, 9 s,CW) on apical one-third of both buccal and lingual roots. The irradiation was repeated every 48 h for fourteen days. Intravenous tetracycline was used to observe newly formed dentin in the first, third, seventh, and fourteenth days. The distance between tetracycline lines (DTL) was examined by Fluorescence microscopy. Generalized estimating equations (GEE) were used for data analysis. In all assessments, the mean DTL were greater in the CHL group. However, the two groups had no significant differences in the amount of deposited dentin between the first and third, third and seventh, and first and seventh lines. Meanwhile, there was a significant difference between the two groups in terms of the distances between lines 7 and 14, 1 and 14 and also 3 to 14 (P < .001). In other words, from the 7th day onwards, there was a significant difference between the two groups. Within the limitation of this study, the combination therapy of PBMT and pulpotomy with calcium hydroxide accelerated apexogenesis in immature permanent dogs' teeth.

Minimally interventive restorative care of teeth with molar incisor hypomineralization and open apex-A 24-month longitudinal study.

AIM: To assess the efficacy of treatment using a minimally invasive approach (selective removal of carious tissue, restoration and preventive strategies) in immature permanent molars with MIH. DESIGN: A total of 281 patients, aged 6-8 years, with carious lesions (ICDAS 5-6), severe MIH, and incomplete root formation (one tooth/patient) were included. After clinical and radiographic examinations, selective carious tissue removal was performed, and the teeth received interim restoration for 6 months and were then restored with composite resin. Clinical and radiographic follow-up was undertaken, 6, 12, 18, and 24 months. A protocol of preventive oral care measures was established and repeated at each follow-up, including diet counselling, oral hygiene instruction, dental plaque control, and topical application of fluoride varnish containing CPP-ACP. All clinical procedures and evaluations were done by a single operator. RESULTS: Clinical and radiographic success was observed 24 months after treatment in 96.8% of the cases. Failures were due to enamel fracture at restoration margins, resulting in pulpitis and absence of apex closure. CONCLUSION: Selective removal of carious tissue, interim, and subsequently definitive restoration, combined with home and professional preventive measures, maintained marginal integrity of restorations in immature permanent molars with severe MIH, confirmed by pulp vitality and occurrence of apexogenesis.

Management of immature necrotic permanent teeth with regenerative endodontic procedures - a review of literature.

Immature necrotic permanent tooth presents a distinctive challenge for the endodontist. Various treatment modalities have been employed to create hard tissue barrier at the apex, which includes non-vital pulp therapy with calcium hydroxide, apexification with mineral trioxide aggregate, pulp revascularisation and regeneration. Regenerative endodontics is a novel modality which involves physiological replacement of the damaged structures of tooth like dentin, root and cells of the pulp-dentin complex. Numerous published case reports have revealed increased dentinal wall thickness, continued root development and apical closure, but there is still lack of sound scientific evidence regarding histological nature of the type of tissue. The current literature review was planned to summarise the evidence regarding the treatment of immature necrotic permanent teeth by regenerative endodontic procedures.

Management of Traumatized Immature Vital Tooth: A Case Report.

Trauma to front tooth is one of the disturbing conditions for children and parents. The treatment strategies used to treat the immature young dentition are important for the long-term prognosis of teeth and should aim at preserving pulp vitality to secure tooth maturation and root development. This article describes a case of trauma to upper front tooth with open apex. The patient was treated with vital pulp therapy with mineral trioxide aggregate to induce apexogenesis.

Apicogénesis en canino permanente joven con resorción intracoronal pre eruptiva: reporte de caso / Apexogenesis in young permanent canine with pre-eruptive intracoronal resortion: case report

Los dientes permanentes presentan desarrollo y formación radicular incompleta al momento de su erupción, el tejido pulpar es el encargado de culminar el proceso de formación radicular por intermedio de los odontoblastos que producen dentina, si la misma se ve afectada por traumatismo, lesión cariosa, resorción intracoronal pre eruptiva (PEIR por sus siglas en inglés) y/o fractura, se altera la vitalidad e incluso puede llegar a producirse necrosis pulpar, lo que ocasionará una interrupción de la formación radicular normal. Para el tratamiento de dientes permanentes jóvenes e inmaduros que han sufrido algún tipo de lesión, pero que aún mantienen la vitalidad pulpar, el procedimiento de apicogénesis con agregado de trióxido mineral (MTA) puede ser considerado como una opción viable, debido a la biocompatibilidad y capacidad de inducir la formación de tejidos duros. En el presente reporte de caso se presenta una pieza dental con antecedente de PEIR, tratada mediante apicogénesis con MTA, lográndose resultados favorables en cuanto al engrosamiento de paredes dentinales, desarrollo radicular y mantenimiento de la vitalidad pulpar.

The permanent teeth have an incomplete development and root formation at the time of its eruption, the pulp tissue is responsible for completing the process of root formation by means of odontoblasts that produce dentin, if it is affected by trauma, carious lesion, Pre-eruptive intracoronal resorption (PEIR) and / or fracture, pulp vitality is altered and pulp necrosis may even occur, which will cause an interruption of the normal radicular formation. For the treatment of immature permanent teeth that have suffered some type of injury, but still maintain pulp vitality, the procedure of apexogenesis with added mineral trioxide (MTA) can be considered as a viable option, due to the biocompatibility and capacity of induce the formation of hard tissues. In this case report we present a tooth with a history of PEIR, treated by apexogenesis with MTA, achieving favorable results in terms of thickening of dentinal walls, root development and maintenance of pulpal vitality.

Comparison between the Outcomes of Two Platelet-Rich Concentrates on Apexogenesis in Young Permanent Incisors Requiring Endodontic Retreatment.

Platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) have been successfully used for inducing pulp regeneration in nonvital teeth. This case report highlights the difference between the outcomes of using PRF and PRP for pulp regeneration in a 13-year-old male patient, who had reported with endodontic treatment failure in his upper incisors. Gutta-percha and sealant were removed, and triple antibiotic paste (TAP) was placed in all the root canals and sealed with cavit. Subsequently, after TAP removal, 11 and 12 were treated with PRF, while 21 and 22 were treated with PRP. A resorbable matrix was placed over the PRF/PRP, over which mineral trioxide aggregate and glass ionomer cement were placed. After 2 years, all the upper maxillary incisors revealed dentinal wall thickening, root lengthening, and apical closure. However, apical bridge formation occurred only in incisors treated with PRF.

Induced post-traumatic apexification: 20 year follow-up and morphological study after new fracture.

Apexification is an endodontic technique used in immature necrotic teeth, the primary goal of which is to induce a calcified barrier in roots with open apices and to promote the continuation of apical root development. A 7-year-old patient with a coronal fracture in a maxillary central incisor was treated with an apexification technique using calcium hydroxide. The apical closure was obtained after one year, then a permanent root canal filling was performed. The tooth was monitored for a period of 20 years, up to when a trauma caused its extraction. The newly formed root was analyzed macroscopically, histologically and through scanning electron microscopy. A morphologically normal root was observed, with a large apex and accessory foramina, showing a combination of tissue structures similar to secondary and tertiary dentine, close to amorphous mineralized areas. Despite the final evolution of the case, calcium hydroxide apexification is a good therapy in order to treat pulp necrosis in an immature tooth, leading to complete development of the root and allowing the tooth to be kept in the mouth.

El rol de la pasta triple antibiótica en endodoncia regenerativa: una revisión bibliográfica / The role of the triple antibiotic paste in regenerative endodontics: a review of the literature

El tratamiento endodóntico convencional en casos de dientes con desarrollo radicular incompleto y periodontitis apical incluye opciones como la cirugía endodóntica o laapexificación mediante el uso de hidróxido de calcio o del compuesto de minerales trióxido. Sin embargo, numerosos ensayos ex vivo e in vivo en modelos animales, así como estudios clínicos en humanos, han demostrado que, luego de una adecuada desinfección y la formación de un coágulo sanguíneo, la posibilidad de obtener la regeneración de los tejidos infectados dentro del espacio del sistema de conductos radiculares –permitiendo a su vez la continuación del desarrollo de la raíz en DDRI con periodontitis apical– es actualmente una realidad con evidencia científicacomprobada. En ese sentido, la combinación de tres antibióticos talescomo metronidazol, ciprofloxacina y minociclina –conocida como pasta triple antibiótica– ha demostrado ser muy efectiva para obtener el nivel de desinfección necesaria. El propósito del presente estudio fue analizar la bibliografía referida al rol de la pasta triple antibiótica en endodoncia regenerativa para el tratamiento de dientes con desarrollo radicular incompleto con periodontitis apical.