Apexification: A systematic review

Successful retreatment of a maxillary central incisor with a wide-open apex using MTA to fill the entire canal: 24-year follow-up

Managing teeth with open apices can be a challenging scenario for clinicians. This case report describes the 24-year follow-up of a maxillary central incisor that failed to develop after a traumatic injury resulting in a wide-open apex. A 10-year-old girl presented complaining of discomfort in her upper teeth. Tooth #9 had received a traumatic blow several years before and was discoloured with a resin composite restoration on the mesio-incisal edge. The tooth was painful to percussion and palpation. An inadequate root canal filling and incomplete root formation were observed on the initial periapical radiograph. Root canal retreatment was initiated, and the canal filled entirely with mineral trioxide aggregate (MTA) because of the extremely wide canal and open apex. The patient was asymptomatic at the 24-year follow-up with the cone beam computed tomography and periapical radiographs demonstrating the stability of the MTA.

Cost-Effectiveness Analysis of Regenerative Endodontics versus MTA Apexification

INTRODUCTION

With the introduction of stem cell engineering in dentistry, regenerative endodontics has emerged as a potential alternative to mineral trioxide aggregate (MTA) apexification in the management of necrotic immature permanent teeth. However, the utility of this modality in terms of cost-effectiveness has not yet been established. Therefore, we performed cost-effectiveness analysis to determine the dominant treatment modality that would influence decision making from the private payer perspective.

METHODS

A Markov model was constructed with a necrotic immature permanent tooth in a 7-y-old patient, followed over the lifetime using TreeAge Pro Healthcare 2022. Transition probabilities were estimated based on the existing literature. Costs were estimated based on United States health care, and cost-effectiveness was determined using Monte Carlo microsimulations. The model was validated internally by sensitivity analyses, and face validation was performed by an experienced endodontist and health economist.

RESULTS

In the base-case scenario, regenerative endodontics did not turn out to be a dominant treatment option as it was associated with an additional cost of USD$1,012 and fewer retained tooth-years (15.48 y). Likewise, in the probabilistic sensitivity analysis, regenerative endodontics was again dominated by apexification against different willingness-to-pay values.

CONCLUSION

Based on current evidence, regenerative endodontic treatment was not cost-effective compared with apexification in the management of necrotic immature permanent teeth over an individual's lifetime.

KNOWLEDGE TRANSFER STATEMENT

The study provides valuable insight regarding the cost valuation and cost-efficacy of regenerative endodontic treatment versus apexification in the management of necrotic immature permanent teeth, as this would aid in effective clinical decision making, allowing for the functional allocation of resources.

Outcomes of apexification in immature traumatised necrotic teeth and risk factors for premature tooth loss: A 20-year longitudinal study

BACKGROUND/AIM

To evaluate the long-term survival of immature traumatized incisors with pulp necrosis and apical periodontitis after endodontic treatment with two apexification techniques (calcium hydroxide apexification and MTA-apical plug) and to identify major factors affecting the survival of these teeth.

MATERIALS AND METHODS

Records of 2400 children and adolescents were screened for presence of traumatic dental injuries to immature incisors where endodontic treatment with the two apexification techniques was performed during January 2003 and December 2022, compared to a control group of mature teeth treated with conventional endodontic techniques. The studied variables were age; sex; apexification technique, presence of luxation and hard tissue injuries; preoperative root development stage (RDS), preoperative and postoperative periapical index (PAI), the time-point for tooth loss, and overall survival time in years. Kaplan-Meier estimates were used to graphically present the survival functions and Cox proportional hazard model to calculate hazard ratios (HR, 95% CI).

RESULTS

The median survival time was 10 years for calcium hydroxide apexification, 16.1 for MTA-apexification, for luxation injuries other than intrusions and avulsions 15.5 years, for intrusions 12.5 years and for avulsions 6.8 years. The variables with significant negative impact on tooth survival were calcium hydroxide apexification, avulsion and postoperative PAI 3-5. No significant relationships were found for the variables MTA apexification, concussion; subluxation; lateral luxation; extrusion, intrusion, hard tissue injuries, preoperative RDS and PAI scores and postoperative PAI 1-2. After adjustment, the risk for premature tooth loss was 13.5 times higher in calcium hydroxide apexification, approximately 2 to 4 times higher in PAI 3-5, and 5.6 times higher in avulsions.

CONCLUSIONS

Calcium hydroxide apexification, avulsion, and postoperative PAI 3-5 were identified as prognostic variables with significant negative impact on the risk for premature tooth loss.

Effects of Access Cavity Design and Placement Techniques on Mineral Trioxide Aggregate Obturation Quality in Simulated Immature Teeth: A Micro-Computed Tomography Study

Background and Objectives: In teeth with open apices, performing single session apexification is a challenging treatment due to the difficulty in handling mineral trioxide aggregate (MTA). Minimally invasive approaches in dentistry have also influenced the cavity designs in endodontics. Until now, different techniques have not been investigated in addition to manual condensation during the process of placing MTA in traditional (TradACs) or conservative (ConsACs) endodontic access cavities. The aim of this in vitro study was to compare and evaluate the obturation quality of MTA apical plugs placed with different techniques in TradACs or ConsACs. Materials and Methods: Sixty upper central teeth were divided into two main groups based on cavity design, and then each main group was further divided into three subgroups according to MTA placement techniques (n = 10): TradAC-manual, TradAC-manual + indirect ultrasonic activation, TradAC-manual + XP-endo Shaper (XPS), ConsAC-manual, ConsAC-manual + indirect ultrasonic activation, and ConsAC-manual + XPS. Subsequently, the porosity percentages in the MTA apical plug were analyzed using micro-computed tomography. The statistical analysis was performed using the Kruskal-Wallis H test and Mann-Whitney U test. Statistical significance was set at p < 0.05. Results: There were differences in volume of porosity percentages (%) according to cavity designs and MTA application techniques (p < 0.05). Except for the XPS group, more porosity was observed in ConsACs compared to TradACs. In TradACs, the significantly lowest open and total porosity was observed in the manual, ultrasonic, and XPS techniques, respectively. In ConsACs, the significantly lowest porosity was observed in the manual, XPS, and ultrasonic techniques, respectively (p < 0.05). Conclusions: In MTA obturation, cavity designs and application techniques had an impact on the MTA porosity. Creating an apical plug in ConsACs may result in more porosity compared to TradACs, especially when manual or indirect ultrasonic activation is preferred. Opting for the manual technique alone may be considered sufficient for controlling porosity for both TradACs and ConsACs.

Advanced Management of Open Apex Utilizing Platelet-Rich Fibrin and Bone Graft As Apical Barriers With Mineral Trioxide Aggregate (MTA) Obturation: A Detailed Case Report

Management of open apex cases in endodontics poses a significant challenge, especially in immature teeth with necrotic pulps. Traditional apexification techniques have been the mainstay of treatment, aiming to induce the formation of a calcific barrier at the root apex. However, newer approaches incorporating biological materials such as platelet-rich fibrin (PRF) and demineralized bone matrix (DMBM) have emerged as promising alternatives. This article presents a case report of an 18-year-old male patient who presented with fractured upper central incisors, with the upper right central incisor displaying an open apex due to trauma sustained eight years prior. The treatment plan involved apexification using a combination of DMBM and PRF, with mineral trioxide aggregate (MTA) utilized as an apical barrier. The procedure was performed under rubber dam isolation, meticulously removing necrotic pulp tissue, irrigating with sodium hypochlorite solution, and placing a calcium hydroxide medicament. Subsequent visits included the placement of DMBM and PRF mixture into the canal space to create an apical barrier, followed by MTA placement and final restoration. Follow-up examinations at 3 and 12 months revealed the tooth to be asymptomatic and functionally normal, with radiographic evidence of osseous repair and complete apical closure. This case underscores the efficacy of a multimodal approach utilizing DMBM, PRF, and MTA in successfully managing open apex cases. Further research and long-term follow-up studies are warranted to validate this treatment modality's predictability and long-term success.

Dental Pulp Cell Transplantation Combined with Regenerative Endodontic Procedures Promotes Dentin Matrix Formation in Mature Mouse Molars

Regenerative endodontic procedures (REPs) are promising for dental pulp tissue regeneration; however, their application in permanent teeth remains challenging. We assessed the potential combination of an REP and local dental pulp cell (DPC) transplantation in the mature molars of C57BL/6 mice with (REP + DPC group) or without (REP group) transplantation of DPCs from green fluorescent protein (GFP) transgenic mice. After 4 weeks, the regenerated tissue was evaluated by micro-computed tomography and histological analyses to detect odontoblasts, vasculogenesis, and neurogenesis. DPCs were assessed for mesenchymal and pluripotency markers. Four weeks after the REP, the molars showed no signs of periapical lesions, and both the REP and REP + DPC groups exhibited a pulp-like tissue composed of a cellular matrix with vessels surrounded by an eosin-stained acellular matrix that resembled hard tissue. However, the REP + DPC group had a broader cellular matrix and uniquely contained odontoblast-like cells co-expressing GFP. Vasculogenesis and neurogenesis were detected in both groups, with the former being more prominent in the REP + DPC group. Overall, the REP was achieved in mature mouse molars and DPC transplantation improved the outcomes by inducing the formation of odontoblast-like cells and greater vasculogenesis.

Evaluating the Effectiveness of a Virtual Simulation Platform for Apexification Learning

The traditional teaching methods for apexification face difficulties in meeting dental students' practical training needs. Herein, we aimed to find optimal techniques of learning apexification and to evaluate whether a virtual simulation platform for apexification learning was effective. A virtual simulation learning platform for apexification was developed. Ninety-nine 4th-year dentistry students were classified randomly into the control group (Con, receiving conventional teaching) and the experimental group (Exp, receiving virtual simulation teaching). Theoretical tests before (test 1) and after the virtual simulation training (test 2) assessed the effect of learning. In the Exp group, a questionnaire was used to assess student understanding of the virtual simulation platform. In the Exp group, the test-2 scores were significantly better compared those in the Con group (p < 0.001). Furthermore, in the Exp group, the test-2 scores exceeded those of test 1 (p < 0.001). Feedback using the questionnaire covered the evaluation of the Exp group for the virtual reality platform and offered useful suggestions. Applying the virtual simulation learning platform had positive effects on improving learning quality related to apexification.

Effect of radiation therapy on fracture resistance of simulated immature teeth submitted to root reinforcement

BACKGROUND

The literature is scanty regarding the effect of radiation therapy (RT) on the mechanical properties of immature permanent teeth.

AIM

To evaluate the effect of RT on the fracture resistance of simulated immature teeth submitted to different types of root reinforcement.

DESIGN

Sixty-four human teeth simulating the Cvek stage 3 of root development were distributed into eight groups (n = 8), according to exposure or not to RT (70 Gy) and the root reinforcement method: Group NR (control)-no reinforcement/no RT; Group NR + RT (control)-no reinforcement/RT; Group PO-tricalcium silicate-based cement (TS) apical plug/canal obturation/no RT; Group PO + RT-TS apical plug/canal obturation/RT; Group TS-canal filling with TS/no RT; Group TS + RT-canal filling with TS/RT; Group FP-TS apical plug/fibreglass post/no RT; and Group FP + RT-TS apical plug/fibreglass post/RT. Fracture resistance was determined using a universal testing machine (0.5 mm/min).

RESULTS

In the intergroup comparison, nonirradiated teeth had higher fracture resistance (p < .05). Groups FP and FP + RT had higher fracture resistance (p < .001).

CONCLUSION

Radiotherapy affected the fracture resistance of simulated immature teeth. Reinforcement with fibreglass posts increased the fracture resistance, regardless of the radiation.

Regenerative Endodontic Procedures of Immature Permanent Premolars with Periapical Lesions: A Report of Two Cases Using Two Different Materials, 18-Month Follow-Up

Regenerative endodontic procedure is an emerging alternative to traditional therapies for immature teeth with necrotic pulp with or without periapical lesions. This innovative approach, also known as revitalization procedures, is aimed at enhancing canal wall thickness, stimulating root lengthening, and promoting apical closure. The regenerative endodontic procedures involve minimally invasive cleaning to preserve stem cells, stimulation of bleeding and clot formation within the canal, and the use of biomaterials to stimulate differentiation. This method is the first choice in biologically based treatments for immature permanent teeth. We present two successful clinical cases in which regenerative endodontic procedures were performed on permanent premolars with necrotic pulp with symptomatic apical periodontitis and chronic apical abscess due to dens evaginatus. The same procedure was employed for both cases, utilizing two differential materials: ProRoot MTA (Dentsply Tulsa Dental Specialities, USA) and Biodentine™ (Septodont, Saint-Maur-des-Fossés, France). Both cases exhibited positive clinical and radiographic outcomes after an 18-month follow-up period including periapical healing, increased dentin thickness, root lengthening, and apical closure.

KDM4D enhances osteo/dentinogenic differentiation and migration of SCAPs via binding to RPS5

OBJECTIVES

Stem cells of the apical papilla (SCAPs) provide promising candidates for dental pulp regeneration. Despite great advances in the transcriptional controls of the SCAPs fate, little is known about the regulation of SCAP differentiation.

MATERIALS AND METHODS

Short hairpin RNAs and full-length RNA were used to deplete or overexpress lysine demethylase 4D (KDM4D) gene expression. Western blotting, real-time RT-PCR, alizarin red staining, and scratch migration assays were used to study the role of KDM4D and the ribosomal protein encoded by RPS5 in SCAPs. RNA microarray, chromatin Immunoprecipitation (ChIP), and co-immunoprecipitation (Co-IP) assays were performed to explore the underlying molecular mechanisms.

RESULTS

KDM4D enhanced the osteo/dentinogenic differentiation, migration, and chemotaxis of SCAPs. The microarray results revealed that 88 mRNAs were differentially expressed in KDM4D-overexpressed SCAPs. ChIP results showed knock-down of KDM4D increased the level of H3K9me2 and H3K9me3 in CNR1 promoter region. There were 37 possible binding partners of KDM4D. KDM4D was found to combine with RPS5, which also promoted the osteo/dentinogenic differentiation, migration, and chemotaxis of SCAPs.

CONCLUSIONS

KDM4D promoted the osteo/dentinogenic differentiation and migration potential of SCAPs in combination with RPS5, which provides a therapeutic clue for improving SCAPs-based dental tissue regeneration.

Effect of conventional needle irrigation, passive ultrasonic irrigation, sonic irrigation and XP-endo finisher in removing intracanal Vitapex paste

To compare the efficiency of conventional needle irrigation, passive ultrasonic irrigation, sonic irrigation and XP-endo Finisher in removing Vitapex paste from root canals. The root canals of human single-rooted teeth were prepared and obturated with Vitapex paste. After 2 weeks, the 48 teeth were randomly allocated into four groups: conventional needle irrigation (CNI) group, passive ultrasonic irrigation (PUI) group, sonic irrigation (SI) group and XP-endo Finisher (XP) group. The specimens of four groups were scanned using a micro-computed tomography after the Vitapex pastes was removed. The results showed that more residual paste was left in the CNI group than in the other three groups (p < 0.05). There was no significant difference among the PUI, SI and XP group (p > 0.05). And, the majority of the residual Vitapex was found in the apical third, with a small amount in the middle third after using any of the three agitated irrigation techniques.

Attitude and practice of regenerative endodontic procedures among endodontists and paediatric dentists: A multinational survey from 13 countries

BACKGROUND

Regenerative endodontics (RET) refers to biologically based procedures that aim to restore damaged tooth structures and reinstate the pulp-dentine complex to its normal physiological state.

AIM

The purpose of this study was to examine the attitudes and practices of endodontists and paediatric dentists regarding RET.

DESIGN

A survey was conducted among endodontists and paediatric dentists from 13 countries. A number of factors were evaluated, including frequency of RET application, followed guidelines, disinfection techniques, intracanal medication type, scaffold type, preferred coronal seal material, and follow-up period.

RESULTS

Among the 1394 respondents, 853 (61.2%) and 541 (38.8%) were endodontists and paediatric dentists, respectively. Almost half (43%) of participants have not performed RET yet. The American Association of Endodontics guideline (47.3%) was selected as the primary source for the clinical protocol. The most frequently selected irrigant solution was 1.5%-3% NaOCl at the first (26.1%) and second (13.6%) sessions. A blood clot (68.7%) and MTA (61.9%) were the most frequently selected scaffold type and coronal barrier. Most participants preferred a 6-month follow-up period.

CONCLUSION

According to this survey, deviations exist from current RET guidelines regarding all aspects evaluated. Standardizing clinical protocols and adhering to available guidelines would help to ensure more predictable outcomes.

Contemporary Endodontic Approaches for Children

Endodontic therapy is necessary when caries extend further into the tissues of the tooth and reach the pulp, producing irreparable inflammation or necrosis [...].

Regenerative endodontic treatment of immature permanent teeth after mechanical instrumentation with XP-Endo Finisher

INTRODUCTION

The traditional treatment of immature permanent teeth with necrotic pulp involves creating an apical barrier by using calcium hydroxide or an MTA plug for an extended period of time. A novel therapeutic approach called regenerative endodontic procedures (REP) is used to allow root development to continue.

Semaphorin 4D Induces Vasculogenic Differentiation of Dental Pulp Stem Cells

This work aimed to evaluate the effect of Semaphorin 4D (SEMA4D) signaling through Plexin B1 on the vasculogenic differentiation of dental pulp stem cells. We assessed the protein expression of SEMA4D and Plexin B1 in dental pulp stem cells (DPSC) from permanent human teeth and stem cells from human exfoliated deciduous (SHED) teeth using Western blots. Their expression in human dental pulp tissues and DPSC-engineered dental pulps was determined using immunofluorescence. We then exposed dental pulp stem cells to recombinant human SEMA4D (rhSEMA4D), evaluated the expression of endothelial cell differentiation markers, and assessed the vasculogenic potential of rhSEMA4D using an in vitro sprouting assay. Lastly, Plexin B1 was silenced to ascertain its role in SEMA4D-mediated vasculogenic differentiation. We found that SEMA4D and Plexin B1 are expressed in DPSC, SHED, and human dental pulp tissues. rhSEMA4D (25-100 ng/mL) induced the expression of endothelial markers, i.e., vascular endothelial growth factor receptor (VEGFR)-2, cluster of differentiation (CD)-31, and tyrosine kinase with immunoglobulin-like and EGF-like domains (Tie)-2, in dental pulp stem cells and promoted capillary-like sprouting in vitro (p < 0.05). Furthermore, Plexin B1 silencing abrogated the vasculogenic differentiation of dental pulp stem cells and significantly inhibited capillary sprouting upon exposure to rhSEMA4D. Collectively, these data provide evidence that SEMA4D induces vasculogenic differentiation of dental pulp stem cells through Plexin B1 signaling.

Different endodontic treatments induced root development of two nonvital immature teeth in the same patient: A case report

BACKGROUND

Pulp revascularization is a novel way to treat immature teeth with periapical disease, and the technique has become increasingly well established in recent years. By puncturing the periapical tissue, bleeding is induced, and a blood clot is formed in the root canal. The blood clot acts as a natural bioscaffold onto which mesenchymal stem cells from periapical tissue can be seeded and restore pulp vascularity, thus promoting root development as well as apical closure. Although the effect of pulp revascularization is ideal, there are certain requirements for the apical condition of the teeth. The apical barrier technique and apexification are still indispensable for teeth that cannot achieve ideal blood clot formation. In addition, a meta-analysis of several clinical studies concluded that pulp revascularization has no significant advantages over other treatments.

CASE SUMMARY

A 10-year-old girl complained of pain in the right upper and lower posterior teeth for 2 d. Clinical and radiological examinations revealed that both the right maxillary and mandibular second premolars were immature with periapical radiolucency. The right maxillary second premolar was treated by pulp revascularization, while the right mandibular second premolar was treated by conventional apical barrier surgery after revascularization failed. The purpose of this report is to compare the different root maturation processes induced by the pulp revascularization and apical barrier techniques in the same patient in homonymous teeth from different jaws. Twelve months of follow-up showed that the apical foramen of both teeth presented a clear tendency to close; however, the tooth treated with pulp revascularization showed a significant increase in root length as well as root canal wall thickness.

CONCLUSION

For the treatment of nonvital immature teeth, pulp revascularization showed a superior therapeutic effect in comparison with the apical barrier technique.

Bioceramics in Endodontics: Updates and Future Perspectives

Bioceramics, with excellent bioactivity and biocompatibility, have been widely used in dentistry, particularly in endodontics. Mineral trioxide aggregate (MTA) is the most widely used bioceramic in endodontics. Recently, many new bioceramics have been developed, showing good potential for the treatment of endodontic diseases. This paper reviews the characteristics of bioceramics and their applications in various clinical endodontic situations, including root-end filling, root canal therapy, vital pulp therapy, apexification/regenerative endodontic treatment, perforation repair, and root defect repair. Relevant literature published from 1993 to 2023 was searched by keywords in PubMed and Web of Science. Current evidence supports the predictable outcome of MTA in the treatment of endodontic diseases. Although novel bioceramics such as Biodentine, EndoSequence, and calcium-enriched mixtures have shown promising clinical outcomes, more well-controlled clinical trials are still needed to provide high-level evidence for their application in endodontics. In addition, to better tackle the clinical challenges in endodontics, efforts are needed to improve the bioactivity of bioceramics, particularly to enhance their antimicrobial activity and mechanical properties and reduce their setting time and solubility.

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.

Clinical Outcome and Comparison of Regenerative and Apexification Intervention in Young Immature Necrotic Teeth-A Systematic Review and Meta-Analysis

This systematic review aimed to evaluate interventions individually and compare the clinical outcome of young, immature teeth treated with regenerative endodontic therapy (RET) and apexification procedure. The protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews), bearing the registration number CRD42021230284. A bibliographic search in the biomedical databases was conducted in four databases—PubMed, CENTRAL, EMBASE and ProQuest—using searching keywords and was limited to studies published between January 2000 and April 2022 in English. The search was supplemented by manual searching, citation screening and scanning of all reference lists of selected paper. The study selection criteria were randomized clinical trial, prospective clinical studies and observational studies. The search found 32 eligible articles, which were included in the study. The quality assessment of the studies was performed using the Cochrane risk of bias tool for randomized control trials and non-randomized clinical studies. The meta-analysis was performed using Review Manager software (REVMAN, version 5). The results indicated that a clinicians’ MTA apexification procedure was more successful compared to calcium hydroxide. In RET, apical closure and overall success rate is statistically same for both apical platelet concentrates (APCs) and blood clots (BC). Both interventions have similar survival rates; however, RET should be preferred in cases where the root development is severely deficient, there is insufficient dentine and the tooth’s prognosis is hopeless even with an apexification procedure.

Regenerative Endodontics Success Factors and their Overall Effectiveness: An Umbrella Review

Introduction

Regenerative endodontics is a developing field of dentistry and aims to recover the physiological and anatomical functions of the tooth for cases of severe dental caries, pulpal pathologies and dental trauma.

Materials and Methods

This umbrella review seeks to discover the scientific evidence on the effectiveness and the factors result in successful regenerative endodontic therapies in teeth with necrotic pulps and with incomplete root development. The study was conducted following the PRISMA Guidelines. There were no restrictions regarding search period. A comprehensive literature search was carried out in EMBASE, LILACS, PubMed, Cochrane, Scopus, and Google Scholar. A quality evaluation was conducted by using AMSTAR-2. A descriptive analysis of the included systematic reviews and meta-analysis were conducted.

Results

Thirteen descriptive systematic reviews and 7 meta-analyses were included. Three articles evidenced low methodological quality according to AMSTAR-2 tool. Overall success rates for the endodontic regeneration procedures ranged from 50% to 98% and the survival rates were between 94% and 100%. Pulp regeneration had a high success rate, evidenced by factors such as the resolution of symptoms, healing, increased root length, dentin thickening and recovery of sensitivity. Follow-up varied from 1 to 48 months for the original studies included in the systematic reviews and meta-analyses.

Conclusions

Endodontic practice offers the clinician a good treatment option in case of necrotic pulp with immature roots such as the endodontic regeneration, that is supported by high and moderate quality scientific literature.

Radiographic differences observed following apexification vs revascularization in necrotic immature molars and incisors: a follow-up study of 18 teeth

PURPOSE

To evaluate the effectiveness of apexification versus revascularization in the treatment of necrotic immature teeth and determine which strategy affords the greatest radiological success rate.

METHODS

An analysis was made of 18 teeth subjected to mineral trioxide aggregate (MTA) apical plugging and regenerative endodontic treatment, assessing healing of the apical lesions and the changes in root dimensions.

RESULTS

Significantly greater root growth was observed with revascularization in terms of the percentage change in length (12.75% at 6 months) and dentin thickness (34.57% at 6 months) (p < 0.05). There were no significant differences between the two treatments in terms of the apical healing scores after 6 months of follow-up (p > 0.05).

CONCLUSION

Apexification with an MTA apical plug and pulp regeneration are reliable treatments for non-vital immature teeth. The radiographic outcomes are comparable between the immature teeth subjected to MTA apexification versus those subjected to revascularization. The results of the present study indicate a greater increase in root length and width with regenerative endodontic treatment.

An Immature Traumatic Teeth Management With Apical Pathology Using the Novel Biodentine™ Obturation: A Case Report

Pulpal and periapical pathosis in an immature anterior tooth following traumatic injury is a frequent occurrence, and management of open apices in such cases poses a constant challenge to endodontists. This is due to the absence of apical constriction that would result in poor three-dimensional seal/adaptation of the obturated material within the canal system. Treatment of immature pulpless teeth with long-term calcium hydroxide may consequently weaken the dentin and increase the fracture susceptibility. Obturating the root canals completely with bioactive agents like Biodentine/mineral trioxide aggregate (MTA) has benefits like increased fracture resistance when compared to apexification. When used for obturation, Biodentine™, a new calcium silicate-based cement, performs superior to other Portland cement derivatives. This case report demonstrates a six-month follow-up result of an open apex and a periapical lesion involving maxillary right central incisor #11 with the Biodentine obturation that was previously subjected to triple antibiotic paste as an intra-canal medicament for three weeks. The satisfactory healing rate of tooth 11 with the reduction in the size of periapical radiolucency at the end of the six-month follow-up in this current article is highly considerable. 

Evaluation of Healing of Periapical Tissue in Permanent Incisors with Open Apices after Unintentional Extrusion of Mineral Trioxide Aggregate - A Retrospective Study

Aim

The aim of the present study was to retrospectively assess the healing of periapical lesions in permanent central incisors with open apices after unintentional extrusion of mineral trioxide aggregate (MTA).

Materials and Methods

The clinical and radiographic records of 75 maxillary permanent central teeth treated by MTA apexification were evaluated. Teeth with unintentionally extruded MTA formed the study group (Group 1, n = 28), whereas the teeth with no MTA extrusion formed the control group (Group 2, n = 47). For both the groups, the records were analyzed for a follow-up period of 3 years.

Results

Complete healing (CH) was observed in 25 teeth in the study group, whereas all the teeth in the control group showed CH (P > 0.05). Within the study group, 6 teeth (21%) showed CH in the 6^th month in Group 1, whereas in the control group, 34 teeth (72.3%) showed CH (P < 0.001). At the 1-year follow-up appointment, 19 teeth (67.8%) showed CH in Group 1, whereas 9 teeth (19.1%) showed the same result in Group 2 (P < 0.001). At the end of the 3-year follow-up period, it was noticed that in 21 (84%) teeth, extruded MTA remained unchanged, whereas it was reduced in 4 (16%) of them (P < 0.001).

Conclusion

Extrusion of MTA does not have a significant effect on the healing of the periapical lesion. However, it may lead to a delay in the healing of periapical healing. Patients should be informed about the complication and consequences of extruded MTA and should be kept on follow-up to observe periapical healing.

Combined Management of Apical Root Fracture and Avulsion of Two Maxillary Permanent Central Incisors: A Case Report

As a result of a skiing accident, a ten-year-old girl suffered combined injuries to both maxillary central incisor teeth (#1.1 and #2.1). The injuries were uncomplicated crown fractures, apical horizontal root fractures, and a severe extrusive luxation of the coronal segments of the teeth. Her mother repositioned the teeth immediately, resulting in good initial healing. Nine months later, the patient was referred to a specialist to manage the endodontic consequences of the trauma. The apexification treatment of the fractured roots, using a preformed apical barrier technique with bioactive cement, was the treatment of choice, administered to both the avulsed roots at two separate recall visits. The best option for managing the fractured apical segments was to continue with the follow-up, which was conducted to assess the overall case at 30 months. The fractured apexes remained normally positioned inside the socket and were asymptomatic (as they presumably maintained a physiological vascular-nerve supply and, consequently, their vitality), while the apexification treatment led to the healing of the periodontal tissues and to hard tissue formation in the area of the interrupted roots in the avulsed portion of the teeth. The management of traumatic injuries in teeth often requires multiple treatment approaches, because these injuries rarely represent one single type of trauma.

Effect of mineral trioxide aggregate and biodentine™ on fracture resistance of immature teeth dentine over time: in vitro study

PURPOSE

The aim of this in vitro study was to evaluate the effect of root filling with White Mineral Trioxide Aggregate (WMTA) and Biodentine™ (BD) on the fracture resistance of simulated immature teeth over different time periods.

METHODS

Sixty sound-extracted human single-rooted premolars were randomly allocated into 3 groups, 2 experimental and 1 control group, with 20 teeth each. Simulation of roots into immature apices were done using Peeso reamers. After preparation, the root canals of teeth in the experimental groups were completely filled with either WMTA or BD. The control group was subdivided into positive controls (n = 10) which received no treatment and negative controls (n = 10) which were prepared the same way and filled with normal saline. The specimens were subjected to fracture testing using a universal testing machine after 2 weeks and 3 months. The peak load to fracture and the fracture location were recorded.

RESULTS

Regarding fracture resistance, the MTA group had the highest fracture resistance at 2 weeks testing, while at 3 months there was no significant difference between the groups (P > 0.05). Regarding fracture location, at 2 weeks there was no significant difference in the fracture location between the groups, while at 3 months, the difference was significant (P < 0.05), the middle root fracture being the most frequent (63.3%).

CONCLUSION

No significant difference in fracture resistant of simulated immature teeth was observed after 3 months when they were filled with Biodentine or WMTA, indicating that Biodentine could be a suitable substitute for MTA. There was no difference in the possible fracture location at 2 weeks, while after 3 months middle root fractures were more frequent.

Incorporation of amoxicillin-loaded microspheres in mineral trioxide aggregate cement: an in vitro study

Objectives

In this study, we investigated the potential of amoxicillin-loaded polymeric microspheres to be delivered to tooth root infection sites via a bioactive reparative cement.

Materials and Methods

Amoxicillin-loaded microspheres were synthesized by a spray-dray method and incorporated at 2.5% and 5% into a mineral trioxide aggregate cement clinically used to induce a mineralized barrier at the root tip of young permanent teeth with incomplete root development and necrotic pulp. The formulations were modified in liquid:powder ratios and in composition by the microspheres. The optimized formulations were evaluated in vitro for physical and mechanical eligibility. The morphology of microspheres was observed under scanning electron microscopy.

Results

The optimized cement formulation containing microspheres at 5% exhibited a delayed-release response and maintained its fundamental functional properties. When mixed with amoxicillin-loaded microspheres, the setting times of both test materials significantly increased. The diametral tensile strength of cement containing microspheres at 5% was similar to control. However, phytic acid had no effect on this outcome (p > 0.05). When mixed with modified liquid:powder ratio, the setting time was significantly longer than that original liquid:powder ratio (p < 0.05).

Conclusions

Lack of optimal concentrations of antibiotics at anatomical sites of the dental tissues is a hallmark of recurrent endodontic infections. Therefore, targeting the controlled release of broad-spectrum antibiotics may improve the therapeutic outcomes of current treatments. Overall, these results indicate that the carry of amoxicillin by microspheres could provide an alternative strategy for the local delivery of antibiotics for the management of tooth infections.

Host defense peptide IDR-1002 associated with ciprofloxacin as a new antimicrobial and immunomodulatory strategy for dental pulp revascularization therapy

Regenerative therapies such as dental pulpal revascularization appear as an option for traumatized immature permanent teeth. However, the triple antibiotic paste - TAP (metronidazole, minocycline, and ciprofloxacin), used for these therapies, can generate cytotoxicity and dentin discoloration. In contrast, host defense peptides (HDPs) are promising antimicrobial and immunomodulatory biomolecules for dentistry. This study aimed to evaluate in vitro the antimicrobial activity (against Staphylococcus aureus and Enterococcus faecalis) and the immunomodulatory potential (by the evaluation of IL-1α, IL-6, IL-12, IL-10, TNF-α and NO, in RAW 264.7 macrophages and IL-6, TGF-β and NO, in L929 fibroblast) of synthetic peptides (DJK-6, IDR-1018, and IDR-1002), compared to TAP in an in vitro infection model containing heat-killed antigens from E. faecalis and S. aureus. Furthermore, the synergistic potential of ciprofloxacin and IDR-1002 was evaluated by checkerboard. Ciprofloxacin was the best antimicrobial of TAP, besides acting in synergism with IDR-1002. TAP was pro-inflammatory (p < 0.05), while the association of ciprofloxacin and IDR-1002 presented an anti-inflammatory profile mainly in the presence of both heat-killed antigens (p < 0.05). Based on these results, ciprofloxacin associated with IDR-1002 may demonstrate an efficient antimicrobial and immunomodulatory action in this in vitro model. Further in vivo studies may determine the real potential of this combination.

The Vital Pulp Therapy of Permanent Teeth: A Dental Practitioner's Perspective from Saudi Arabia

AIMS AND OBJECTIVES

The aim of this study was to determine the levels of knowledge and attitude of dental practitioners (DPs) toward vital pulp therapy (VPT) of young permanent teeth in Riyadh city, Saudi Arabia.

MATERIALS AND METHODS

A descriptive cross-sectional study was carried out by taking convenient sample of general DPs and specialist attending Saudi International Dental Conference, Riyadh, Saudi Arabia. A total of 200 DPs administered a structured, self-administered questionnaire to evaluate their knowledge and attitude toward VPT. The questionnaire comprised four parts: Part I: Characteristics of the study participants; Part II: Items related to indications and diagnosis of VPT; Part III: Questions related to the different VPTs for immature permanent teeth; and Part IV: Dental materials used in VPT and restoration. All the data were entered into the statistical analysis software Statistical Package for the Social Sciences version 21.0 (IBM, Armonk, NY) and analyzed by using descriptive statistics of frequency distribution and percentages for the categorical variables.

RESULTS

A total of 193 (men = 57% [110] and women = 43% [83]) DPs participated in this study with a response rate of 96.5%. Less than half of correct responses were observed with (Item 1) related to the duration of complete closure of root apex (43%) and (Item 14) use of sodium hypochlorite to serve as an excellent diagnostic tool to differentiate irreversible from reversible pulpitis. A high percentage of correct responses were seen with the (Item 9) indirect pulp capping--a procedure performed in a tooth with a deep carious lesion without signs or symptoms of pulp degeneration (75%). All other item responses ranged in between 52% and 72%.

CONCLUSION

DPs showed fair-to-good knowledge and attitude toward VPT of young permanent teeth. In general, there is a need to improve knowledge and attitude of dental professionals about the VPT by attending continuing dental educational programs.

Comparative evaluation of fracture resistance of simulated immature teeth and its effect on single visit apexification versus complete obturation using MTA and biodentine

AIM AND OBJECTIVES

This study sought to evaluate and compare the fractured resistance of simulated immature teeth and the effect of single visit apexification versus complete obturation using MTA and biodentine.

MATERIAL AND METHODOLOGY

Forty-five freshly extracted sound maxillary central incisors with single canal were selected. The apical 5 mm of each sample was then sectioned to simulate Cvek's stage 3 root development access cavity preparation, followed by preparation using peeso reamers. Irrigation was carried out followed by randomization of samples. Obturation was performed using different materials. Fracture resistance was checked under universal testing machine, by recording the ultimate load to fracture in Newtons.

STATISTICAL ANALYSIS

Statistical analysis was performed using SPSS 20.0 Software. One-way analysis of variance followed by pair wise comparison of the groups was performed using Tukey's post-hoc test. The significance level was set at P < 0.05.

RESULTS

All the experimental groups showed statistically higher value of fracture resistance than the control groups. Group I (entire canal obturated with MTA) reported highest value of fracture resistance followed by group III (entire canal obturated with biodentine), group II, and group IV.

CONCLUSION

In apexification cases, reinforcing the immature teeth with bioceramic materials such as MTA and biodentine is advantageous.

CLINICAL SIGNIFICANCE

Clinically in patients, high success rate of apexification can be achieved with complete MTA obturation as compared to MTA and biodentine apical plug and gutta percha obturation.

Periostitis ossificans in a 10-year-old child

Periostitis ossificans (PO) is a type of osteomyelitis stemming from an odontogenic infection, generally found in children and adolescents, and often leads to the loss of the involved tooth. This case presents a less invasive alternative for the treatment of PO. A 10-year-old patient presented with an asymmetrical increase in the left side of the mandible. Tooth 36 exhibited pulp necrosis and incomplete root formation. Radiographically, the bone in the region had the appearance of the layers of an onion. Computed tomography indicated periosteal bone proliferation in the region of the ramus and angle of the mandible adjacent to the vestibular cortical bone. Therapy involved root canal preparation and intracanal medication with calcium hydroxide in tooth 36. Complete remission of the condition occurred within 14 months. In conclusion, endodontic intervention is a less invasive alternative and should be considered to minimize the negative impact of tooth loss in children.