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Biologically Based Treatment of Immature Permanent

Teeth with Pulpal Necrosis: A Case Series


Il-Young Jung, DDS, MS,* Seung-Jong Lee, DDS, MS,* and Kenneth M. Hargreaves, DDS, PhD

Abstract
This case series reports the outcomes of 8 patients
(ages 9 14 years) who presented with 9 immature
permanent teeth with pulpal necrosis and apical peri-
odontitis. During treatment, 5 of the teeth were found
to have at least some residual vital tissue remaining in
the root canal systems. After NaOCl irrigation and
medication with ciprofloxacin, metronidazole, and mi-
nocycline, these teeth were sealed with mineral trioxide
aggregate and restored. The other group of 4 teeth had
no evidence of any residual vital pulp tissue. This
second group of teeth was treated with NaOCl irriga-
tion and medicated with ciprofloxacin, metronidazole,
and minocycline followed by a revascularization proce-
dure adopted from the trauma literature (bleeding
evoked to form an intracanal blood clot). In both groups
of patients, there was evidence of satisfactory postop-
erative clinical outcomes (15 years); the patients were
asymptomatic, no sinus tracts were evident, apical
periodontitis was resolved, and there was radiographic
evidence of continuing thickness of dentinal walls, api-
cal closure, or increased root length. (J Endod 2008;34:
876 887)
Key Words
Endodontics, immature permanent tooth, open apex,
regenerative, revascularization, stem cell
A
lthough contemporary nonsurgical endodontic procedures confer high degrees of
clinical success (1, 2), the root canal system is obturated with synthetic materials,
preventing any of the advantages that might ensue by regeneration of a functional
pulp-dentin complex (3). This is a particular problem when treating the necrotic but
immature permanent tooth, where conventional treatment often leads to resolution of
apical periodontitis, but the tooth remains susceptible to fracture (4) as a result of
interruption of apical and dentinal wall development. Thus, one alternative approach
would be to develop and validate biologically based endodontic procedures designed to
restore a functional pulp-dentin complex.
For more than 50 years, clinicians have evaluated biologically based methods to
restore a functional pulp-dentin complex in teeth with necrotic root canal systems
caused primarily by trauma or caries. Although case series from the 1960s1970s in
general were not successful in producing this outcome (5, 6), it should be appreciated
that they were performed without contemporary instruments or materials and without
insight generated from the trauma or tissue engineering fields (7). More recent case
reports, published during the last 15 years, have demonstrated that it is possible in
humans to restore a functional pulp-dentin complex in the necrotic immature perma-
nent tooth (8 13). Human histologic studies have not yet been reported, so it is not
known whether these treatments truly recapitulate the normal pulp-dentin complex.
However, these case studies provide some measure of achieving satisfactory functional
outcomes, because postoperative recalls indicate that the patient is asymptomatic, no
sinus tracts are present, apical periodontitis is resolved, and there is radiographic
evidence of continuing thickness of dentinal walls, apical closure, or development of
root length.
Although case series do not provide definitive evidence to support a given treat-
ment modality, they do have the advantage of being conducted in actual patients and thus
provide greater insight than preclinical studies. Moreover, the results from case series
can be used to identify potentially important parameters that can guide the design of
future prospective clinical trials. For example, in nearly all published case series on
pulpal regeneration, an effort was made to evoke an intracanal blood clot to trigger
tissue ingrowth. In this case series, we report conditions in which it was not necessary
to evoke intracanal bleeding to have continued root development.
Pulp Regeneration without Formation of a Blood Clot
Case 1
A 10-year-old girl was referred to the Department of Conservative Dentistry of the
Dental Hospital of Yonsei University by an oral and maxillofacial surgeon for evaluation
on the right second mandibular premolar (tooth #29). The girl had a history of swelling
of the right mandibular buccal vestibule, for which she received an incision for drainage
procedure at the Department of Oral and Maxillofacial Surgery 2 months earlier. On
clinical examination, the patient was slightly symptomatic to percussion, and a sinus
tract was present that traced to the apex of tooth #29. The first and second premolars
were free of caries, but a fracture of an occlusal tubercle of tooth #29 was noted on
visual inspection. Periodontal probings were within normal limits for all teeth in the
lower right region. Diagnostic testing was inconclusive on cold and electric pulp testing,
but the patient reported sensitivity to percussion or palpation. Periradicular radio-
graphic examination revealed that tooth #29 had an incompletely developed apex and
a periradicular radiolucency (Fig. 1A). The diagnosis of pulp necrosis and chronic
apical abscess with a sinus tract was made for tooth #29.
From the *Department of Conservative Dentistry, Yonsei
University School of Dentistry, Seoul, Korea; and

Department
of Endodontics, University of Texas Health Science Center at
San Antonio, San Antonio, Texas.
Address requests for reprints to Dr Seung-Jong Lee, De-
partment of Conservative Dentistry, Yonsei University School
of Dentistry, 134 Shinchon-Dong, Sudaemun-Ku, Seoul, Korea
120-752. E-mail address: SJLee@yuhs.ac.
0099-2399/$0 - see front matter
Copyright 2008 American Association of Endodontists.
doi:10.1016/j.joen.2008.03.023
Case Report/Clinical Techniques
876 Jung et al. JOE Volume 34, Number 7, July 2008
Figure 1. (A) Radiographic image showing an incompletely developed apex and a periradicular radiolucency of tooth #29. Note the sinus tract that traces to the apex
of tooth #29. (B) Radiographic viewpresenting a gutta-percha cone tracing to tooth #29, and a periradicular radiolucency associated with tooth #28. (C) Radiograph
from 60-day follow-up visit after both teeth were medicated with triantibiotic paste. The sinus tract is still traced to the apex of tooth #29. The thickness of temporary
filling material does not seemto be appropriate for both teeth. (D) The radiograph demonstrating complete resolution of the radiolucency and continued development
of the apex of both teeth at 6-month follow-up. (E) Follow-up at 5 years.
Case Report/Clinical Techniques
JOE Volume 34, Number 7, July 2008 Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis 877
When the access cavity was made under rubber dam isolation, a
purulent hemorrhagic exudate discharged from the canal. The tooth
was left open until the discharge of the exudate had stopped. After
the exudate had almost stopped, a K-file was inserted into the canal.
The patient did not complain of any sensation until the file tip was in the
middle part of the canal. In addition, a little resistance by residual tissue
was felt in the mid-portion of the canal, and the patient had a sensation
of pain at that time. On the basis of these findings, the possibility was
raised that at least some vital pulp tissue remained in the canal, and
therefore we used a method similar to that reported by Iwaya et al. (8)
in an attempt to achieve regeneration of the pulp tissue complex. The
root canal was irrigated with 5% NaOCl for 10 minutes and dried with
paper points, and a mixture of ciprofloxacin, metronidazole, and mi-
nocycline paste as described by Hoshino et al. (14) was introduced into
the canal with a lentulo spiral. The access cavity was closed with Caviton
(GC, Aichi, Japan). No mechanical instrumentation was performed dur-
ing the procedure.
The patient returned a week later, asymptomatic, reporting no
pain postoperatively. However, the sinus tract was still present. The
access cavity was opened, and the root canal was slowly flushed with 10
mL of 5.25%NaOCl, and irrigation was continued for 15 minutes. Unlike
the first visit, a mixture of erythromycin and Ca(OH)
2
was placed into
the root canal. The patient returned 2 weeks later. The sinus tract was
still present, and the patient complained of slight discomfort in tooth
#28. A size #30 gutta-percha cone was threaded into the opening of the
sinus tract, and a periapical radiograph was taken. Radiographic exam-
ination showed that a sinus tract was traced to the apex of tooth #29, and
a periradicular radiolucency was suspected around tooth #28 (Fig. 1B).
The clinical examination revealed that moderate percussion pain was
associated with teeth #28 and #29. Diagnostic testing was inconclusive
on cold and electric pulp testing on tooth #28. A diagnosis of pulp
necrosis and chronic apical periodontitis was made for tooth #28.
An access cavity was made on tooth #28, and the necrotic nature of
the upper part of the root canal was confirmed. However, some vital
pulp tissue seemed to remain in the apical part of the canal because
insertion of a K-file to this point evoked a sensation of pain and some
bleeding. The root canal was slowly flushed with 10 mL of 5.25%NaOCl
and irrigated with the same solution for 15 minutes. The same proce-
dure was performed on tooth #29. Both teeth were medicated with the
triantibiotic paste described by Hoshino et al. (14).
The patient returned 10 days later. The pain intensity had been
reduced, and the sinus tract was not present. To conduct a more de-
tailed evaluation of the patient, the next appointment was made 2 weeks
later. However, the patient failed to return for the appointment. The
patient returned 50 days later, complaining of the reappearance of the
sinus tract and spontaneous pain. The sinus tract was traced to the apex
of tooth #29, and both teeth (teeth #28 and #29) were tender to per-
cussion. The temporary filling material appeared to be intact, but the
radiograph revealed the thickness of the material was not appropriate
for both teeth (Fig. 1C). Because microleakage was a possibility, the
canal disinfection was repeated as before. A week later, the patient
returned, and the sinus tract was closed. The canal was reirrigated with
NaOCl, and Ca(OH)
2
paste (Vitapex; Neo Dental Chemical Products,
Tokyo, Japan) was placed, followed by Caviton temporary restoration.
At the 6-month recall, the patient was asymptomatic. The radio-
graph showed complete resolution of the radiolucency, and continued
development of the apex was also observed (Fig. 1D). After removal of
the Caviton and Ca(OH)
2
paste, calcific barriers were evident in both
teeth by intracanal exploration with a #30 F-file. Permanent gutta-per-
cha fillings were performed with Obtura (Obtura Corporation, Fenton,
MO) and Sealapex (Kerr Co, Romulus, MI) followed by a bonded resin
restoration. At the 5-year follow-up, the patient continued to be asymp-
tomatic, and closure of the apex and thickening of the dentinal walls
were obvious in both teeth (Fig. 1E).
Case 2
A 10-year-old boy was referred to the Department of Conservative
Dentistry of the Dental Hospital of Yonsei University for evaluation of
tooth #29. The boy had reported slight discomfort in the lower right
region for 1 month, but he was asymptomatic during the examination
visit. On clinical examination, a sinus tract was present that traced to the
apex of tooth #29. The tooth was free of caries, but fracture of the
occlusal tubercle was noted on visual inspection. Diagnostic testing was
inconclusive on cold and electric pulp testing, with sensitivity noted after
percussion or palpation. The periodontal probings were within normal
limits for the tooth. Periradicular radiographic examination revealed
that tooth #29 had an incomplete apex and a periradicular radiolucency
(Fig. 2A). The diagnosis of pulp necrosis and chronic apical abscess
with a sinus tract was made for tooth #29.
When the access cavity was made, a purulent hemorrhagic exudate
discharged from the access opening (Fig. 2B). After the control of the
blood exudate with saline irrigation, there appeared to be some remain-
ing soft tissue in the root canal. The same regenerative technique mod-
ified from Iwaya et al. (8) and used in Case 1 was repeated for this
patient. The root canal was irrigated with 5.25% NaOCl and replaced
every 5 minutes for a total of 30 minutes. A mixture of ciprofloxacin,
metronidazole, and minocycline paste was placed into the root canal
with a lentulo spiral, and the access cavity was closed with Caviton.
The patient returned 11 days later. The patient was asymptomatic,
and the sinus tract was resolved. The root canal was slowly flushed with
10 mL of 5.25% NaOCl and continuously irrigated with the same solu-
tion for 15 minutes. The root canal was dried with paper points, and
mineral trioxide aggregate (MTA) (Dentsply Tulsa Dental, Tulsa, OK)
was carefully placed over the tissue in the root canal followed by inter-
mediate restorative material (IRM) (Caulk Dentsply, Milford, DE) (Fig.
2C). A radiograph taken 3 months after MTA placement revealed a slight
increase of the thickness of the root canal wall and continued develop-
ment of the apex (Fig. 2D). The IRM was replaced with a bonded resin
restoration. At the 2-year follow-up, the patient continued to be asymp-
tomatic, and closure of the apex and thickening of the dentinal walls
were obvious (Fig. 2E).
Case 3
A 10-year-old boy was referred for evaluation and treatment of the
left mandibular second premolar (tooth #20). The patient reported a
throbbing pain in the lower left region for the preceding 10 days. The
patients dentist had treated tooth #20 because of the presence of swell-
ing around the tooth. Drainage was established by occlusal access and
incising the buccal vestibule a day before our examination. At the time of
our examination, the tooth was moderately tender to percussion, and
the canal remained open with a cotton pellet and therefore exposed to
the oral environment. A fluctuant swelling was present in the lingual
attached gingiva of the tooth, and the incision line on the buccal vesti-
bule also remained (Fig. 3A). A periodontal examination revealed prob-
ing depths of 3 mmor less. Radiographic examination showed a perira-
dicular radiolucency (Fig. 3B).
After rubber dam isolation, the cotton pellet was removed. Slight
bleeding was evident from the canal, and there seemed to be some vital
tissue remaining in the apical half of the canal because insertion of a
K-file evoked a sensation of pain. The root canal was irrigated with 5%
sodium hypochlorite replaced every 5 minutes for a 30-minute period.
Then a mixture of ciprofloxacin, metronidazole, and minocycline paste
was introduced into the canal via a lentulo spiral.
Case Report/Clinical Techniques
878 Jung et al. JOE Volume 34, Number 7, July 2008
Figure 2. (A) Radiographic image showing an incompletely developed apex and a periradicular radiolucency of tooth #29. Note the sinus tract that traces to the apex
of tooth #29. (B) Photograph of a purulent hemorrhagic exudate discharged from tooth #29. (C) Radiograph presenting the placement of MTA. (D) 3-month recall
radiograph. A slight increase of the thickness of the root canal wall and continued development of the apex are observed. (E) Two-year radiograph showing continued
root development.
Case Report/Clinical Techniques
JOE Volume 34, Number 7, July 2008 Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis 879
Figure 3. (A) Photograph demonstrating a fluctuant swelling in the lingual attached gingiva of tooth #20. (B) Radiograph showing a periradicular radiolucency
associated with tooth #20. Note that the canal has remained open and therefore exposed to the oral environment. (C) Radiograph presenting the placement of MTA
and IRM. (D) Radiograph demonstrating a slight increase of the thickness of the root canal wall and the formation of dentin bridge under MTA at 2-month follow-up.
(E) Ten-month radiograph showing complete resolution of the radiolucency and continued development of the apex.
Case Report/Clinical Techniques
880 Jung et al. JOE Volume 34, Number 7, July 2008
The patient returned 30 days later. The patient was asymptom-
atic, and the sinus tract was resolved. However, when we removed
the intracanal dressing material, a slight amount of bleeding was
observed. The root canal was irrigated with 5% NaOCl for 30 min-
utes. Ca(OH)
2
paste was placed into the canal. The patient returned
40 days later. The patient was asymptomatic, and the radiograph
showed resolution of the radiolucency. After rubber dam isolation,
the root canal was slowly flushed with 10 mL of 5.25% NaOCl and
irrigated with same solution for 15 minutes. The root canal was
dried with paper points, and MTA was carefully placed over the
tissue in the root canal followed by IRM (Fig. 3C). A radiograph
taken 2 months after MTA placement showed that a slight increase of
the thickness of the root canal wall and a mineralized bridge ap-
peared to develop beneath the MTA (Fig. 3D). At the 10-month
follow-up, the patient continued to be asymptomatic, and continued
development of the apex was also observed. The IRM was replaced
with a bonded resin restoration (Fig. 3E).
Case 4
A 13-year-old boy was referred for evaluation and treatment of the
left second premolar. Before the visit to our clinic, the patient reported
a moderate pain in the lower left region and sought dental care in a local
clinic. The patients dentist at the local clinic thought the pain originated
fromthe necrotic pulp of tooth #20 and started the root canal treatment
without local anesthesia. The dentist informed us that when he opened
the pulp chamber, active hemorrhagic exudate discharged from the
canal. He tried to negotiate the distal canal but failed. At the time of our
examination, the tooth was asymptomatic and remained sealed with
temporary filling material. Clinical examination revealed periodontal
probings 3 mmfor the tooth, and an abnormal finding such as a sinus
Figure 4. (A) Radiographic illustrating a large periapical radiolucency associated with the apex of tooth #20. (B) Radiograph presenting the placement of MTA and
IRM. (C) Two-month radiograph revealing some reduction in the periapical radiolucency. (D) Radiograph demonstrating excellent periapical healing at 2-year
follow-up.
Case Report/Clinical Techniques
JOE Volume 34, Number 7, July 2008 Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis 881
tract was not found. Periradicular radiographic examination revealed
that tooth #20 had a bifurcated apex and a periradicular radiolucency
10 mm in diameter (Fig. 4A). When we removed the temporary filling
material and observed the root canal system with an operating micro-
scope, some tissue was found in apical third of the root canal. Copious
irrigation was performed with 5.25% NaOCl for 30 minutes, and a
mixture of ciprofloxacin, metronidazole, and minocycline paste was
placed into the canal with a lentulo spiral. The patient returned 2 weeks
later and reported no postoperative pain. After rubber dam isolation,
the root canal systemwas slowly flushed with 10 mL of 5.25%NaOCl and
irrigated with the same solution for 15 minutes. The root canal was
dried with paper points, and MTA was carefully placed over the tissue in
the root canal followed by IRM (Fig. 4B). A radiograph taken 2 months
after MTA placement showed that some reduction in the radiolucency
was evident (Fig. 4C). At the 2-year follow-up, the radiograph showed
complete resolution of the radiolucency (Fig. 4D).
Pulp Regeneration after Formation of a Intracanal
Blood Clot
Case 5
A 10-year-old girl experienced painful symptoms in her mandib-
ular left second premolar that required evaluation and treatment. Her
dentist informed her parents that there was a large cavity in the tooth.
Root canal treatment was initiated, but she did not return to the local
clinic at the next appointment. Instead, she presented at our clinic for
completion of treatment of the tooth approximately 3 months later. The
canal had remained open and exposed to the oral environment, but the
tooth was asymptomatic. The periodontal probings were 3 mm, and
an abnormal finding such as a sinus tract was not observed. A radio-
graph revealed a periradicular radiolucency around the incompletely
formed apex of tooth #20 (Fig. 5A). To prevent leakage during the
treatment or interappointment period, the tooth was restored with a
bonded resin restoration.
One week later, the tooth was isolated, and an access cavity was made.
A K-file was introduced into the canal until the patient felt some sensitivity,
and a radiograph was taken (Fig. 5B). No tactile resistance was met with the
K-file until the patient reportedsensitivity. Copious irrigationwas performed
with 2.5% NaOCl for 30 minutes, and a mixture of ciprofloxacin, metroni-
dazole, and minocycline paste was placed into the canal.
The patient returned a week later and reported no further experi-
ence of pain. The root canal was slowly flushed with 10 mL of 2.5%
NaOCl, and irrigation was maintained with same solution for 15 min-
utes. A size #30 K-file was used to irritate the tissue gently to create some
bleeding into the canal. The bleeding was left for 15 minutes so that the
blood would clot. MTA was carefully placed over the blood clot followed
by a wet cotton pellet and Caviton (Fig. 5C). Two weeks later, the patient
returned, asymptomatic, and the Caviton and cotton pellet were re-
placed with a bonded resin restoration. At the 12-month recall, the
patient was asymptomatic, and the radiograph showed complete reso-
lution of the radiolucency, and the canal space occupied by blood clot
was narrowed (Fig. 5D). At the 24-month follow-up, the patient contin-
ued to be asymptomatic, and continued thickening of the dentinal walls
was obvious after radiographic examination (Fig. 5E).
Case 6
A 9-year-old girl was referred for evaluation and treatment of the
mandibular left second premolar. The child had a lingual swelling of the
left mandibular area for 1 week before the appointment. On clinical
examination, the patient was asymptomatic, and the tooth appeared
intact without evidence of caries. The tooth had an open apex associated
with a large radiolucency, and a lingual sinus tract was present that
traced to the apex of tooth #20 (Fig. 6A). Periodontal probings were 3
mm for all teeth in the lower left region. Diagnostic testing was incon-
clusive with cold and electric pulp testing, but sensitivity was reported
after percussion or palpation. The tooth was isolated, and a purulent
hemorrhagic exudate discharged from the canal was evident when the
access cavity was made. The root canal system was irrigated with 2.5%
NaOCl for 30 minutes, the canals were then dried, and a mixture of
ciprofloxacin, metronidazole, and minocycline paste was placed by us-
ing a lentulo spiral. The patient returned a week later and denied a
history of postoperative pain. The root canal was slowly flushed with 10
mL of 2.5%NaOCl. To evaluate whether vital tissue presented in the root
canal, a size #100 gutta-percha cone was introduced into the canal
until the patient reported some sensitivity. A radiograph was taken
and revealed that it had reached the open apex of the tooth (Fig. 6B).
Because the presence of an open apex and thin dentinal walls greatly
increase the risk of future fracture, the regenerative technique as de-
scribed in Case #5 was performed. A size #30 K-file was used to irritate
the tissue gently to create some bleeding into the canal. The bleeding
was left for 15 minutes to permit blood clotting. MTA was carefully
placed over the blood clot. However, the blood clot was so fragile that
some of MTA extruded into the apical third of the canal (Fig. 6C). Two
weeks later, the patient returned, asymptomatic, and the Caviton and
cotton pellet were replaced with a bonded resin restoration. At the
6-month recall, the patient was asymptomatic, and the radiograph
showed complete resolution of the radiolucency, with some continued
development of the apex detected (Fig. 6D). At the 24-month follow-up,
the patient continued to be asymptomatic. Although the presence of
extruded MTA was observed, it was evident that the dentinal walls dis-
played continued thickening with closure of the apex (Fig. 6E).
Case 7
A 14-year-old girl was referred for evaluation on the lower right sec-
ond premolar. The girl had a history of swelling of the right mandibular
buccal vestibule, for which she received an incision for drainage at the local
clinic a week earlier. At the time of our examination, the tooth had an open
apex associated with a radiolucency, and a buccal sinus tract was present
that traced to the apex of tooth #29 (Fig. 7A). Periodontal probings were
within normal limits for all teeth in the lower right region.
The tooth was isolated, an access cavity was made, copious irriga-
tion with 2.5% NaOCl was continued for 30 minutes, and an aqueous
mixture of Ca(OH)
2
was placed into the canal. A week later, the patient
returned, asymptomatic, and the sinus tract was resolved. The root
canal was slowly flushed with 10 mL of 2.5%NaOCl. To evaluate whether
vital tissue presented in the root canal, a size #100 gutta-percha cone
was introduced into the canal until the patient reported some sensation.
A radiograph was taken at that point and revealed that the sensation was
only felt when the gutta-percha reached the open apex (Fig. 7B). A size
#30 K-file was used to irritate the tissue gently to create some bleeding
into the canal. The bleeding was left for 15 minutes so that the blood
would clot. MTA was carefully placed over the blood clot (Fig 7C).
Three weeks later, the patient returned asymptomatic, and the Caviton
and cotton pellet were replaced with a bonded resin restoration. The
patient returned 1 year later with no symptoms or sinus tract evident.
Radiographic examination revealed a greatly reduced periradicular ra-
diolucency (Fig. 7D).
Case 8
A 10-year-old girl experienced painful symptoms in her maxillary
right second premolar that required evaluation and treatment. Her den-
tist initiated the root canal treatment on the tooth, but she did not go to
the clinic at next appointment. Approximately 3 months later, she pre-
sented at our clinic for treatment of the tooth. On presentation, the canal
Case Report/Clinical Techniques
882 Jung et al. JOE Volume 34, Number 7, July 2008
Figure5. (A)Radiographobtainedapproximately 3months after theinitial treatment at local clinic. Aperiradicular radiolucency aroundtheincompletely formedapexof tooth
#20 can be seen. (B) Radiograph demonstrating a K-file can be introduced into the canal without local anesthesia. (C) Radiograph presenting the placement of MTA. The MTA
was carefully placed over the blood clot followed by a wet cotton pellet and Caviton. (D) Twelve-month radiograph showing complete resolution of the radiolucency and a
calcification of the canal space occupied by blood clot. (E) Radiograph demonstrating excellent periapical healing at 2-year follow-up.
Case Report/Clinical Techniques
JOE Volume 34, Number 7, July 2008 Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis 883
Figure 6. (A) Periapical radiograph of tooth #20 at initial presentation. A gutta-percha cone traces sinus tract to the periradicular radiolucency associated with tooth
#20. (B) Radiograph demonstrating a gutta-percha cone can be introduced into the canal easily without local anesthesia. (C) Radiograph presenting the placement
of MTA. Note that some of MTA extruded into the apical third of the canal. (D) Six-month recall radiograph. The radiolucency has completely disappeared, and
continued root development can be seen. (E) Radiograph demonstrating thickening of the dentinal walls and closure of the apex at 2-year follow-up.
Case Report/Clinical Techniques
884 Jung et al. JOE Volume 34, Number 7, July 2008
was open to the oral environment, but the tooth was asymptomatic. The
periodontal probings were within normal limits, and an abnormal find-
ing such as a sinus tract was not found. A radiograph showed that a
periradicular radiolucency was evident around the incompletely
formed apex of the tooth (Fig. 8A). The tooth was isolated, an access
cavity was made, copious irrigation was done with 2.5% NaOCl for 30
minutes, and a mixture of ciprofloxacin, metronidazole, and minocy-
cline paste was placed into the canal. At the next appointment (3 weeks
later), the root canal was slowly flushed with 10 mL of 2.5% NaOCl and
continuously irrigated with the same solution for 15 minutes under the
rubber dam isolation. A size #30 K-file was used to irritate the tissue
gently to create some bleeding into the canal, but we failed to achieve
sufficient blood clot to support the MTA filling. Therefore, we used
Collatape (Sulzer Dental Inc, Plainsboro, NJ) as a matrix for the growth
of new tissue into the pulp space. Under the microscope, we could
observe that blood was oozing fromthe periradicular tissue and wetting
the Collatape. MTA was carefully placed over the Collatape followed by
a wet cotton pellet and Caviton (Fig. 8B). A month later, the patient
returned, asymptomatic, and the Caviton and cotton pellet were re-
placed with a bonded resin restoration. At the 17-month recall, the
patient was asymptomatic, and the radiograph showed complete reso-
lution of the radiolucency with continued apical closure (Fig. 8C).
Discussion
This case series described the outcomes of 8 patients who pre-
sented with 9 immature permanent teeth with apical periodontitis. Most
of these cases were associated with a dens evaginatus, where the thin
Figure 7. (A) Periapical radiograph of tooth #29 at initial presentation. A gutta-percha cone traces sinus tract to the periradicular radiolucency associated with tooth
#29. (B) Radiograph demonstrating a gutta-percha cone can be introduced into the canal easily without local anesthesia. (C) Radiograph presenting the placement
of MTA. The MTA was carefully placed over the blood clot followed by a wet cotton pellet and Caviton. (D) Radiograph demonstrating a reduced periradicular
radiolucency at 1-year follow-up.
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JOE Volume 34, Number 7, July 2008 Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis 885
occlusal tubercle might often fracture, predisposing the tooth to bacte-
rial infection and pulpal necrosis (15). The results indicated that it is
possible to treat the necrotic and immature permanent tooth, leading to
a postoperative patient who is asymptomatic without evidence of a sinus
tract and a permanent tooth where apical periodontitis is resolved, and
there is radiographic evidence of continuing thickness of dentinal walls,
apical closure, or further development of root length. This biologic
result is remarkable, given the typically poor prognosis of these
cases (4) and the fact that contemporary treatment approaches
including the use of MTA as an apical plug preclude further root
development (16).
In the first 4 patients, treatment was administered without an at-
tempt to trigger bleeding and the formation of an intracanal clot. It is
interesting to note that all 5 teeth had a preoperative diagnosis of pulpal
necrosis, and this was supported both by the clinical presentation (all
cases had a periradicular radiolucency, and cases #1#3 had either a
sinus tract or an intraoral swelling) and by the lack of pain during
access without local anesthesia. The lack of responsiveness to cold and
electrical testing was not considered in the diagnosis, given the incom-
plete nature of the tooth development (17). Despite these preoperative
diagnoses, some vitality was noted during treatment either by sensitivity
to instrumentation within the root canal systemor by the visual or tactile
perception of soft tissue remaining within the root canal system. These
cases were treated by NaOCl irrigation followed by at least 1-week place-
ment of the triple antibiotic mixture of ciprofloxacin, metronidazole,
and minocycline, although case #1 did require additional treatment to
resolve the sinus tract. The postoperative recall periods of 10
months5 years indicated increased thickening of the dentinal walls
and continual apical closure. Because at least some residual vital
tissue was believed to be present, these 4 cases could be classified as
Figure 8. (A) Radiograph obtained approximately 3 months after the initial treatment at local clinic. A periradicular radiolucency around the incompletely formed
apex of tooth #4 can be seen. (B) Radiograph presenting the placement of MTA. The MTA was carefully placed over Collatape followed by a wet cotton pellet and
Caviton. (C) Radiograph showing complete resolution of the radiolucency with continued apical closure at 17-month follow-up.
Case Report/Clinical Techniques
886 Jung et al. JOE Volume 34, Number 7, July 2008
apexogenesis, although it is not clear whether the continued apical
development was due to cells in the surviving pulp-dentin complex
or to regenerated tissues originating from stem/progenitor cells
located in the apical papilla (18).
In the second set of 4 patients, treatment was administered as
above, with the addition of evoking an intracanal blood clot. These cases
are distinct fromthe first set of 4 cases by the lack of evidence of residual
vital pulp tissue within the root canal system. The initiation of the blood
clot is thought to provide a fibrin scaffold with platelet-derived growth
factors that promotes regeneration of tissue within the root canal system
(9, 19). The clinical outcomes of 3 cases (cases #5, #6, and #8) are very
similar to those observed in the first set of 4 patients, with 3 asymptom-
atic patients returning for postoperative recall periods of 17 months2
years and radiographic evidence of increased thickening of the dentinal
walls and continual apical closure. Case #7 showed some different clinical
outcomes. Although apical periodontitis was resolved in the case, a
narrowing of the canal space was not significant at 1-year follow-up.
Although the clinical outcomes of most cases were consistent with
the hypothesis of a functional restoration of biologic root development,
the precise mechanisms and cellular source remain unknown. It has
been suggested that the radiographic evidence of increased root thick-
ness might be due to ingrowth of dentin, cementum, or bone (13, 19).
The present findings do not distinguish among these possibilities. We do
note that other investigators have published human histologic stud-
ies describing tissue changes in the pulp-dentin complex or peri-
odontium after tooth extraction after various dental treatments (5,
20 22). Although this approach is clearly subject to considerable
ethical issues, including informed consent and strict inclusion cri-
teria, human histologic studies would directly answer the question
of tissue identity after pulpal regeneration/revascularization proce-
dures in patients.
The value of case reports is the demonstration of what is possible
in our patients. Reports from astute clinical practitioners have played
pivotal roles in advancing dental therapeutics including recognition of
the properties of fluoride (23), as well as the adverse effects of bisphos-
phonates (24). The present study, combined with prior reports on
regeneration/revascularization of the nonvital immature permanent
tooth (813), constitute a growing case series suggesting that biologi-
cally based treatment approaches might be of particular value in restor-
ing root development and apical closure in these otherwise difficult
cases. Importantly, the value of prospective randomized clinical tri-
als is their ability to provide strong quantitative evidence for both
treatment efficacy and the potential for adverse effects. This growing
body of case reports provides impetus for developing prospective
randomized controlled trials evaluating these methods. Finally, if
this biologic process can occur in the immature tooth, then it also
might provide some insight into the conditions necessary to regen-
erate a functional pulp-dentin complex in the nonvital fully formed
permanent tooth.
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Case Report/Clinical Techniques
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