Clinical Oral Investigations

https://doi.org/10.1007/s00784-021-04123-z

ORIGINAL ARTICLE

Management of internal inflammatory root resorption using

injectable platelet‑rich fibrin revascularization technique: a clinical
study with cone‑beam computed tomography evaluation
Mohamed Nageh1   · Lamiaa A. Ibrahim1 · Fatma M. AbuNaeem2 · Engy Salam3

Received: 16 February 2021 / Accepted: 30 July 2021

© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objectives  The current study evaluated clinically and radiographically the management of internal inflammatory root resorp-
tion (IIRR) in permanent anterior teeth with or without periapical lesions using injectable platelet-rich fibrin (i-PRF) regen-
erative approach.
Methods  Ten systemically healthy patients, with thirteen anterior mature teeth diagnosed with IIRR were selected for the
study. At the first visit, the tooth was anesthetized, access cavity opened, root canals were mechanically prepared then medi-
cated with calcium hydroxide and temporarily sealed. After 2–4 weeks, regenerative endodontic procedures were performed
by preparing and applying i-PRF inside the canal, then a freshly prepared PRF membrane was placed over it. White mineral
trioxide aggregate was placed over the PRF matrix, and the tooth was restored with a glass ionomer cement base and resin
composite restoration. The patients were recalled for clinical and radiographic evaluation and follow-up every 3 months for
12 months. Cone-beam computed tomography (CBCT) imaging was performed preoperatively and after 12 months.
Results  Clinical evaluation results showed resolution of signs and symptoms through the follow-up period in all of the cases.
Both CBCT imaging readings of IIRR lesions and periapical lesions revealed a volumetric significant difference (p = 0.00)
between the preoperative and the 12-month follow-up period.
Conclusions  Usage of i-PRF could arrest and allow for healing of IIRR in permanent mature teeth and allow for periapical
healing with successful clinical results.
Clinical relevance  i-PRF revascularization technique proved to be a successful REP in the treatment of the IIRR, reducing
the number of appointments and increasing patient compliance.

Keywords  Root resorption · Pulp revascularization · Regenerative endodontics · Injectable platelet-rich fibrin · Cone-beam
computed tomography · Trauma

Introduction

Root resorption (RR) is either a physiologic or a patho-

logical condition that is associated with tooth structure
loss caused by clastic cells. Local pathological root resorp-
tion is a permanent irreversible condition that may be
* Mohamed Nageh caused by apical periodontitis, traumatic dental injury,
mnt12@fayoum.edu.eg autotransplantation, intracoronal bleaching, orthodontic
1 treatment, or idiopathic factor. Root resorption can be
Department of Endodontics, Faculty of Dentistry, Fayoum
University, Batal Al‑Salam Street, Al bahary, Fayoum, Egypt classified into either internal or external according to the
2 damaged protective layer [1]. Internal inflammatory root
Department of Endodontics, Faculty of Dentistry, Cairo
University, 11 Sarya el Manyal Street, Manyal, Cairo, Egypt resorption (IIRR) is somewhat a rare clinical presentation
3 in permanent teeth [2]. It is usually asymptomatic and is
Department of Oral and Maxillofacial Radiology, Faculty
of Dentistry, Fayoum University, Batal Al‑Salam Street, Al detected accidentally through routine radiographs. If it is
bahary, Fayoum, Egypt left untreated, it can perforate the external root surface

13
Vol.:(0123456789)

causing serious complications and may lead to rapid tooth
loss. Moreover, with the progression of this process, the
tooth might become symptomatic and periapical periodon-
titis might develop [3].
The diagnosis and follow-up of IIRR primarily depend
on radiographic examination, patient history, and clinical
findings. However, conventional two-dimensional radio-
graphic imaging is unable to provide neither the exact
location, nor extent, nor nature of a resorptive defect, nor
the thickness of the remaining root canal dentine, particu-
larly in the buccolingual plane. The superimposition of
several anatomical structures and image distortion is a fur-
ther limitation resulting in a limited diagnostic yield from
the conventional radiographic techniques [4].
The recent technology of cone-beam computed tomo-
graphic (CBCT) imaging has enhanced radiographic diag-
nosis, detection of the changes in tooth structure, and the
presence of periapical lesions more accurately than con-
ventional radiographs [4]. It can also display the exact
location and extension of perforations and resorptive
defects [5], which can help in determining the degree of
treatment complexity and aid the clinician in offering an
accurate prognosis [6].
Traditional nonsurgical treatment of non-perforating
IIRR is based on optimum root canal preparation and dis-
infection then obturation using thermoplasticized tech-
niques [3]. Although with the success of these techniques,
it had its own limitations as sealer can dissolve over time,
leading to voids within the canal which may act as a nidus
for reinfection [7].
Recently, bioceramics were used for the obturation of root
canals containing resorptive defects due to their desirable
properties [8]. However, the flow properties of mineral tri-
oxide aggregate (MTA) are significantly poorer than those
of thermoplasticized gutta-percha and its use as an effective
filling material in IRR depends on adequate ultrasonic acti-
vation of the material to disperse it into the recesses of the
defect [9]. Moreover, these techniques cannot replace the
damaged pulp and tooth structure with vital tissues that act
as a defensive mechanism during tissue injury and protection
from further damage or the probability of tooth fracture.
Regenerative endodontic therapy was mainly limited to
pulp revascularization of necrotic pulp in immature teeth
[10] [11] [12] [13] [14], followed by mature teeth [15] [16]
[17] [18]. Recently, pulp revascularization by the induction
of blood clot was applied in the treatment of inflammatory
root resorption [19]. So far, no clinical study for the man-
agement of teeth with IIRR by using injectable platelet-rich
fibrin (i-PRF) revascularization has been reported in the
literature. Thus, the aim of this study is to evaluate the man-
agement of IIRR using i-PRF where this may be the first
clinical attempt to manage IIRR in necrotic incisor teeth
using i-PRF regenerative approach.
13
Clinical Oral Investigations
Materials and method
The number of IIRR defects needed for this study was
calculated prior to investigation using Epi Info software
7.2.4.0. The anticipated success rate of revascularization
using i-PRF in the management of IIRR at 12 months was
95%. Given this assumption, it was necessary to include
a minimum of thirteen resorptive defects in the study in
order to construct a 90% confidence level with a 10% mar-
gin of error.
The protocol of the trial was approved by the Ethics
Committee of the Faculty of Medicine (ID: R/221052018).
The study was conducted in accordance with the ethical
standards as laid down in the 1964 Declaration of Hel-
sinki and its later amendments. Ten systemically healthy
patients, with thirteen anterior mature teeth diagnosed with
IIRR, were selected for the study between 2018 and 2019
from the outpatient clinic of the Faculty of Dentistry. This
study was registered on the website www.​clini​caltr​ials.​gov
(#NCT04410679). The treatment procedures and the aim of
the study were fully explained to all the enrolled patients.
The patients were asked about their dental and medical his-
tory; medically compromised patients who complained of
diabetes mellitus, heart diseases, liver diseases, kidney dis-
eases, autoimmune diseases, cancer, and patients on immu-
nosuppressive drugs were excluded. Inclusion criteria for
the study were patients who are 13–30 years old with no
sex predilection, medically free and are suffering from IIRR
in permanent anterior mature teeth with or without peri-
apical radiolucency. A full history of the chief complaint
was obtained including intensity, quality, onset, duration,
location, course, and initiating and relieving factors of pain.
All the patients had reported a previous traumatic injury
and did not receive any treatment at the time the trauma
had occurred. Eight of the included patients with a total of
ten teeth were complaining of mild to moderate dull pain
on percussion and palpation tests with or without a fistu-
lous tract and complaining of teeth discoloration; the radio-
graphic examination revealed root resorption and periapi-
cal radiolucency. Three anterior teeth in two patients were
asymptomatic, and the diagnosis was established by routine
radiographic examination, which showed root resorption.
Patients and the parents of the enrolled children in the study
were asked to follow the general instructions, sign a printed
informed consent that explained the aim and the steps of the
study and conform to the clinical and radiographic follow-up
period for 12 months. CBCT was requested from the patients
to confirm the diagnosis of internal root resorption differen-
tiating it from external root resorption and to follow up the
treatment outcome after 12 months.
Treatments of IIRR by regenerative endodontic proce-
dures (REP) were carried on according to the American
Clinical Oral Investigations
Association of Endodontics—regenerative endodontics
(AAE) 2016 [20]. At the first visit, the tooth was anesthe-
tized with buccal infiltration technique using 1.8–3.6 mL
2% lidocaine with 1:100,000 epinephrine local anesthetic
solution (Octocaine 100, Novocol, Canada). An access
cavity was performed, and the tooth was isolated with a
rubber dam. The working length was determined using
an electronic apex locator (Root ZX II, J. Morita Mfg.
Corp., Kyoto, Japan) and then confirmed with intraoral
periapical radiography to be 0.5–1 mm shorter than the
radiographic apex. The granulation tissues were effec-
tively removed as much as possible through cleaning and
shaping with a minimum of K-type file size #40 (Mani
Inc., Japan) and maximum with file size #80 (Mani Inc.,
Japan). The canals were thoroughly irrigated between each
successive file using 1.5% sodium hypochlorite (NaOCl)
(Clorox, Egypt). Finally, ultrasonic activation of NaOCl
was carried out for 1 min for better canal disinfection, then
the canals were dried with absorbent paper points (META
BIOMED CO., LTD, Korea), and medicated with calcium
hydroxide (Ca(OH)2) (Hydrocal, Cerkamed, Poland) The
access cavity was temporarily sealed with a sterile cotton
pellet and glass ionomer cement (Ketac Fil Plus Aplicap,
3 M ESPE, USA).
At the second visit (2–4 weeks from the first visit), a
plain anesthesia 1.8 mL 3% mepivacaine (Scandonest, Sep-
todont, Louisville, Canada) buccal infiltration was admin-
istered. The rubber dam was placed, temporary glass iono-
mer cement was removed using a high-speed handpiece and
reirrigation of root canals was performed with 20 mL 17%
EDTA (Prevest, Denpro, India) for 1 min followed by saline
irrigation. The canals were dried using absorbing paper
points.
A 5-mL sample of whole venous blood was drawn from
the patient’s forearm (right median cubital vein) to pre-
pare i-PRF. The blood sample was then transferred into a
Fig. 1  a Collection of the prepared i-PRF using a sterile needle; b injection of i-PRF in the prepared root canal till level of CEJ; c PRF prepara-
tion; d application of the fragmented PRF membrane above i-PRF; e application of MTA above the PRF matrix
nonglass test tube without anticoagulant and centrifuged
immediately using a tabletop centrifuge (VELAB centrifuge
(VE-4000), TX, USA) at 700 revolutions per minute (rpm)
for 3 min [21]. The upper liquid layer was collected as i-PRF
and injected into the teeth root canal until the cementoe-
namel junction (CEJ) (Fig. 1a, b). PRF was prepared accord-
ing to Choukroun’s method [22] and used as a matrix mem-
brane above i-PRF (Fig. 1c, d). A 3-mm-thick layer of white
MTA (ProRoot, Dentsply, USA) was placed directly over the
PRF matrix (Fig. 1e). A moist cotton pellet was placed over
the MTA, and the tooth was temporized using glass ionomer
cement for the complete set of the MTA. The patients were
recalled the next day to remove the cotton pellet, and the
tooth was restored using a glass ionomer cement base and a
resin composite restoration (3 M-ESPE, St. Paul, MN, USA).
The patients were recalled for clinical and radiographic
evaluation and follow-up every 3 months for 12 months.
CBCT (Planmeca, ProMax 3D Max, Finland) was requested
from the patients to confirm the diagnosis of internal or
external root resorption and to follow up the healing pro-
cedures. A scout view was obtained and adjustments were
made to ensure that all patients were correctly aligned with
the following acquisition parameters: 512 × 512 pixels per
slice and 24 bits per pixel. Resultant voxels were isotropic;
the acquisition time for each slice was 12 s and the recon-
struction time was 60 s at an angular increment of 0°. The
operating protocol for all the scans of the study was as fol-
lows: tube voltage 90 kV, 6 mA, voxel size 0.2 mm, exposure
time 12 s, and image size 0.5 × 0.5 cm (251 × 251 × 251).
For CBCT image analysis, data were imported as DICOM
data into Romexis software; multiplanar sagittal, coronal,
and axial projections were generated; certain steps were
followed in each selected scan to standardize the volume
analysis method. Volumetric measurement of the periapi-
cal region was done using the free region grow tools which
apply manual segmentation by drawing outlines of the
13
 Clinical Oral Investigations

segmented area on the sagittal cuts after creating many out- Table 1  Demographic characteristics of the participants
lines on different sagittal slices, following the radiolucent Number Percentage
area on each slice; by clicking create a region, the software
automatically will calculate the volume of the selected Age
region. The volumetric measurement of the IIRR was done 13–18 years 5 50%
using the measure cube tools and adjusting the cube on the 19–24 years 3 30%
sagittal cut, after adjusting the coronal orientation line along 25–30 years 2 20%
the long axis of the affected single-rooted tooth, on the area Sex
of the pulp diagnosed as the area of IIRR. The anterior and Male 7 70%
posterior limit of the cube was created by certifying that the Female 3 30%
IIRR boundaries were included. Then the “3-D region grow- Tooth type
ing” button was used to set the parameter to be used. In the Maxillary central incisor 7 53.8%
“3D region growing” window, the “pre-set” box was set as Maxillary lateral incisor 4 30.8%
“pulp cavity”; the threshold was set at 300, ticked at colored Mandibular central incisor 1 7.7%
by areas, then “select the seed point.” Click on a space in Mandibular lateral incisor 1 7.7%
the pulp cavity at the area of IIRR. Romexis then rendered Site of IIRR
up the pulp and displayed the volume of the selected area Coronal third 4 30.8%
of the pulp [23]. Middle third 4 30.8%
Values were presented as mean, standard deviation (SD), Apical third 5 38.4%
and confidence intervals (CI) values. Data were explored for Trauma as a cause of IIRR
normality using the Kolmogorov–Smirnov test of normal- History of more than 10 years 3 23.1%
ity. The results of the Kolmogorov–Smirnov test indicated History within the last 5–10 years 2 15.4%
that data of IIRR and periapical lesion volumes were non- History within the last 1–4 years 8 61.5%
parametric data; therefore, Wilcoxon signed-rank test was Pulp status
used for intragroup comparisons (preoperative and postop- Vital 3 23.1%
erative). The percent change was calculated by the formula Necrotic 10 76.9%
value after − value before/value before × 100. Data of per-
cent were nonparametric and both variables were compared
by Mann–Whitney U test. The significance level was set from their preoperative volumetric size, indicating repairing
at p ≤ 0.05. Statistical analysis was performed with SPSS by mineralized-like deposits in the resorptive defects (Figs. 3
18.0 (Statistical Package for the Social Sciences, SPSS, Inc., and 4). Ten teeth with preoperative periapical lesion showed
Chicago, IL, USA) for Windows. resolution of apical periodontitis after 12 months (Fig. 3).
The mean volume of IIRR lesions significantly decreased
from (0.004 ± 0.002 ­cm3) preoperatively to (0.003 ± 0.002
Results ­cm3) postoperatively (p = 0.011) (Table 2, Fig. 5). The mean
volume of periapical lesions significantly decreased from
The study included thirteen lesions in ten patients with ages (0.171 ± 0.134 ­cm3) preoperatively to (0.018 ± 0.047 c­ m3)
ranging from 13 to 30 years, with a mean of 12.6 ± 5.7. The postoperatively (p = 0.00) (Table 2, Fig. 5). IIRR lesions
demographic characteristics of the participants are presented showed a percent reduction in the volume of − 21.88%, in
in Table 1. Clinical evaluation results showed that there was comparison to a significantly greater reduction in volume for
no pain, mobility, swelling, or fistula through the follow-up periapical lesions (− 94.04%). The difference between both
period in all of the cases. However, the sensitivity test using percentages was statistically significant (p = 0.00) (Table 3,
the electric pulp tester was negative in all the enrolled cases Fig. 6).
till the present time, and further follow-up for the sensitiv- A post hoc power analysis was run to determine if the
ity regaining is intended. The radiographic images showed selected sample size (n = 13) was sufficient or a larger sam-
neither progression of resorptive defects nor development of ple size was needed to achieve a power of 80%. An effect
new defects in all the enrolled cases. Also, it showed healing size of (1.07) was calculated based on the difference between
of the preoperative periapical lesion cases with neither pro- the lesion size as measured by IIRR pre and postoperatively.
gression of the previous lesions nor newly developed lesions By using the specified significance level (0.05), sample size
(Fig. 2). The CBCT was used to assess the progression or (n = 13), and the calculated effect size (1.07), the power to
regression of the disease through the 12-month follow-up Wilcoxon signed rank test was found to be (0.93, i.e., 93%)
period; it showed promising results. All the included cases and the sample size was deemed sufficient. Power analysis
showed either arrested lesions or progressively decreasing was performed using G*Power version 3.1.9.4 [24].

13
Clinical Oral Investigations
Fig. 2  a Preoperative periapical radiograph showing IIRR in man-
dibular left lateral incisor with the periapical lesion. b The periapical
radiograph taken 3 months postoperatively showing the reduction of
periapical radiolucency size and arrest of the resorption site. c The
periapical radiograph taken 6  months postoperatively showing pro-
Fig. 3  a, b, c Preoperative CBCT image with different cuts in man-
dibular left lateral incisor showing the volumetric size of IIRR and
periapical lesion. d, e, f 12 months postoperative CBCT image with
Discussion
Management of RR is considered a challenge to the dentist
owing to its complicated anatomy. The biological expla-
nation of the mechanism of bone and root resorption is
considered the same; osteoclasts are multinuclear cells
responsible for the resorption of bone, while odonto-
blasts are corresponding cells resorbing dental hard tis-
sues [25]. Their differentiation is under the control of the
gressive reduction of periapical radiolucency size and arrest of the
resorption sites. d The periapical radiograph taken 12  months post-
operatively showing healing of periapical radiolucency and arrest of
resorptive lesion
different cuts in mandibular left lateral incisor showing the decrease
in IIRR volumetric size and healing of periapical lesion
RANK-RANKL-OPG system which serves as an on–off
system for osteoclast activity [26].
Literature has shown that trauma is the principal fac-
tor responsible for internal root resorption followed by
inflammation/infection of the pulp [2] [3] [27]. All patients
included in this study reported a history of traumatic injury
in anterior teeth supporting the findings of a previous study
[28] which stated that dental traumas occur substantially in
the anterior region of the mouth and are more common in
young adults.
13

Fig. 4  a, b, c Preoperative
CBCT image with different cuts
in maxillary left lateral incisor
showing the volumetric size of
IIRR. d, e, f 12 months postop-
erative CBCT image with differ-
ent cuts in maxillary left lateral
incisor showing the decrease in
IIRR volumetric size
Most of the clinical studies on the treatment of RR by
REP focused on the management of external root resorp-
tions [19] [29], whereas no clinical study applied REP for
the management of internal root resorption. This is the first
clinical study to use CBCT technology to evaluate the pro-
gress or regress of internal resorption cavity using i-PRF
revascularization technique, moreover to evaluate the peri-
apical bone healing of the associated periapical lesions.
In the current study, 1.5% NaOCl concentration was used
as a tissue solvent and antimicrobial agent [30]; as a high
concentration of 5.25% NaOCl was found to be cytotoxic to
stem cells in the apical tissues and decrease odontoblastic
differentiation [31]. Vibratory ultrasonic instrumentation
was used to agitate NaOCl to aid in chemical disinfection
and penetration of the irrigant into the resorption cavity and
inaccessible areas, which has been shown to improve the
removal of granulation tissue, organic debris, and biofilms
from the inaccessible resorptive defect of the root canal [3].
Ca(OH)2 was used as an intracanal medicament due to its
excellent antimicrobial effect owing to its high pH 12.5–12.8
[32]. Moreover, it was used to control bleeding of granu-
lation tissue, necrotize the residual pulp tissue, and make
the necrotic tissue more soluble to NaOCl [33]. Ca(OH)2
in REP showed a high number of survival of stem cells
and increased the amounts of transforming growth factor-
b1(TGF-b1) imprisoned in the dentin matrix [34]. Removal
of Ca(OH)2 from the canal was done by gently filling the
root canals and using copious and gentle positive pressure
irrigation with 20 ml 17% EDTA, which can easily remove
the residual intracanal medicament[35].
A solution of 17% EDTA has a chelating effect, which
promotes the release of dentin-derived growth factors that
were previously embedded into dentin during the process of
dentinogenesis [36]. These growth factors have been shown
to stimulate proliferation, survival, and differentiation of
dental stem cells for successful pulp regenerative procedures
[37].
13
Clinical Oral Investigations
The followed hypothesis of pulp revascularization in the
current study depended on the cell homing principle, which
relies on growth factors that cause migration, proliferation,
and differentiation of endogenous stem cells [38]. Sources of
stem cells that could have been attributed to pulp revascular-
ization include periodontal ligament stem cells (PDLSCs),
bone marrow mesenchymal stem cells (BMSCs), inflamma-
tory periapical progenitor cells (IPAPCs) found in apical
periodontitis or periapical abscess, or some surviving dental
pulp stem cells (DPSCs) at the root apex. [39].
Recently, autologous platelet concentrates have been used
widely in dentistry. Different techniques of autologous plate-
let concentrate such as PRP and PRF have been developed
over the years to be used as a source of growth factors and
as a scaffold at the same time. Concerns have been raised
regarding PRP usage as its properties may vary depending
on the number of leukocytes and the concentration of plate-
lets. In addition, bovine thrombin results in sudden fibrin
polymerization with faster physiologic elimination of these
cytokines and release growth factors only over a short period
of time [40]. Furthermore, bovine thrombin with high con-
centration may impair cell migration during tissue healing
[41]. PRF has been developed to overcome the limitations
associated with the use of PRP. Furthermore, it is a highly
resistant and elastic membrane which does not dissolve
quickly after application [22]; allowing the slow continu-
ous release of growth factors [42] which directs efficiently
stem cell migration, proliferation, differentiation, and angio-
genesis [43].
Initial formulations of Choukron’s PRF lacked a liquid
concentrate of proteins as the majority of PRF growth fac-
tors are encapsulated within its fibrin matrix [44]. PRF
membranes should be used immediately after preparation
as they rapidly shrink resulting in dehydration which causes
altering in their structural integrity, leukocyte viability, and
decreased growth factor content which in turn adversely
affect its biologic properties [45].
Clinical Oral Investigations

For these reasons, the i-PRF formulation was evolved

0.011*

0.00*
[46]. It is a liquid formulation of PRF that does not contain

p
any anticoagulants as in PRP or fibrin matrix as in PRF [21].
i-PRF was selected to be used in this study owing to its vari-

2.98

4.84
ous advantages; it is in a liquid form which can be easily
t injected inside the canal and fill in the irregular resorptive
cavities and inaccessible areas; it acts as a source of growth
95% upper CI
factors and a scaffold at the same time. i-PRF was prepared
0.002 by the reduction of centrifugation force by the low-speed

0.221
centrifugation concept which was shown to cause a signifi-
cant increase in regenerative cells, leukocyte, and platelet
numbers, as well as growth factors concentration when com-
pared to other formulations of PRF utilizing higher centrifu-
95% lower CI

gation speeds [47]. Moreover, i-PRF plays an important role

in tissue healing by activating the host defense system as
0.000

0.084
Table 2  Descriptive statistics and comparison between preoperative and postoperative IIRR and periapical lesion volume (­ cm3) (paired t-test)

it has the highest number of platelets and defense-fighting

leukocytes, allowing for antimicrobial potency against bac-
terial lipopolysaccharide when compared to other platelet
Std. dev

concentrates [48]; also, the leukocytes have a crucial role

0.001

0.114
Paired difference

during wound healing by directing and recruiting vari-

ous cell types [49]. Nevertheless, it was observed recently
that i-PRF released lower quantities and concentrations of
Mean

0.001

0.153

growth factors than expected [50], particularly for BMP-2

which is known as an osteogenic cue [51]. However, i-PRF
may produce in the smaller amount a protein cocktail with
Std. error mean

different biochemical cues and may work in a synergetic

manner, leading to a positive biological impact for tissue
regeneration and enhancement of mineralization, and there-
0.001
0.000
0.037
0.013

fore may be the candidate of choice for tissue engineering

approaches utilizing autologous cues to promote hard tissue
regeneration [51].
Std. dev

PRF membrane was used to be placed over the i-PRF

0.002
0.002
0.134
0.047

injected inside the root canal [12] to withstand the compac-

tion forces during the application of the MTA above it and
inhibit MTA from being leaked inside the root canal.
Mean

0.004
0.003
0.171
0.018

In the present study, isotropic voxel with voxel size

0.2 mm and small field of view (FOV) CBCT was used,
therefore it would be convenient and accurate in the inves-
12 months postoperative

12 months postoperative

tigation of limited volumes of root resorption. Small FOV

CBCT and images with small voxel sizes increased observ-
ers’ ability to distinguish between objects with varying
Preoperative

Preoperative

attenuation levels by relatively small distances in any chosen

viewing plane [23] [52] [53]. CBCT shows high sensitivity
Significance level p ≤ 0.05, *significant
Time

in the detection of periapical lesion and assessment of root

resorption, so small FOV and high-resolution CBCT can be
used in cases of IIRR and influence the management and
Periapical lesion volume

prognosis of the tooth. Moreover, CBCT is an accurate and

CI, confidence interval

valuable tool for monitoring the healing rate of apical lesions

IIRR volume (cm3)

by measuring the volume [54] [54] [55].

Few studies have identified the presence, type, and vol-
umetric measurements of RR, but this is the first clinical
study to evaluate the volumetric changes of internal resorp-
(cm3)

tive defects using CBCT, and it showed superior diagnostic

13

Fig. 5  a Bar chart illustrating volumetric size of internal inflammatory root resorption (IIRR) preoperatively and after 12 months. b Bar chart
illustrating volumetric size of periapical lesion preoperatively and after 12 months
Table 3  Comparison of percent change (%) of IIRR and periapical
lesion volume (Mann–Whitney U test)
Percentage change (%) Mean Std. dev Std. error mean p
IIRR  − 21.88 21.29 5.90 0.00*
Periapical lesion volume  − 94.04 12.30 3.41
Significance level p ≤ 0.05, *significant
Fig. 6  Bar chart illustrating mean percent change (%) of IIRR and
periapical lesion volume 12 months postoperatively
accuracy and correct management of root resorption as
found by other studies [56] [57] [58]. Several methods have
been employed to measure the lesions’ volume using cali-
bration cubes [59] [60], spherical phantoms of known size
[61], or calculating volume using either automated segmen-
tation or from manual linear readings [62]. According to
the treatment strategy obligations of the current study, root
canal preparation was done after preoperative CBCT so the
volumetric measurements of the whole root canal size may
13
Clinical Oral Investigations
be affected by the mechanical preparation. Therefore, the
segmentation volumetric technology was not used and the
cube tool with a 3-D region growing window was used to
calculate the volumetric measurements confined only to the
periapical lesion and the IIRR area which was probably not
touched by the cleaning and shaping instruments.
Literature has shown that 12  months is an adequate
follow-up period. Orstavik’s classic study in 1996 of 599
endodontically treated roots showed that the peak incidence
of healing of apical periodontitis was 1 year following treat-
ment [63]. The European Society of Endodontology recom-
mends that the first follow-up examination should be made
1 year after treatment and that if the lesion has failed to
resolve, further follow-up appointments should be completed
every year for a period of 4 years [64]. However, the current
study did not include any conventional root canal treatment,
but it could be considered to follow the 12-month follow-up
as an assessment period. According to a meta-analysis by
Murray in 2018 which included 12 different articles having
222 regenerative cases, hard tissue assessment such as the
closure of apex, root lengthening, dentinal wall thickening,
and healing of periapical lesion was done after 12 months
in all cases [65].
The clinical results of this study were the resolution of
apical periodontitis and the elimination of clinical signs/
symptoms which are considered a success according to the
American Association of Endodontists’ guidelines [66] [67].
Postoperative sensitivity testing is negative until now, and
further follow-up for the sensitivity regaining is intended.
However, sensitivity regaining is not the only factor that
ensures success. Studies on regeneration in literature [15]
[68] [69] considered their outcome a success by observation
of hard tissue deposition, healing of lesions, the function-
ality of the teeth, and the absence of signs and symptoms
Clinical Oral Investigations
while sensitivity was still not achieved. In addition, there
was an arrest and decrease in the volumetric size of the IIRR
defects. There was a statistically significant decrease in the
volumetric measurements of both IIRR defects and periapi-
cal lesions after 12 months. The clinical findings in the cur-
rent study coincided with previous case reports [19] [29]
which confirmed the efficacy of the REP as a viable valuable
treatment option for traumatized teeth with root resorption.
The radiographic results of this study are in accordance with
other reported studies [70] [71] [72] [65] [73] which showed
an increase in the dentin wall thickness, hard tissue forma-
tion on the internal walls of the root canals, and continuous
development of the root and apical closure using different
REP techniques.
Moreover, our results showed successful periapical heal-
ing and were in agreement with reported clinical studies [12]
[74] which showed complete radiographic periapical heal-
ing following PRF revascularization of immature teeth after
12 months. Noteworthy, three teeth from the total included
cases showed no periapical lesion or signs and symptoms
of pulp necrosis, and IIRR was discovered by chance. The
12-month CBCT images of the included 3 teeth showed
the arrest of the IIRR; moreover, the volumetric lesion size
was decreased significantly and no periapical lesion was
developed.
The demographic characteristics of the participants
showed that the age range from 13 to 18 years is 50% of
the total cases and that the other 50% had an age range
from 19 to 30 years old (Table 1). All the involved cases
showed a successful clinical and radiographic outcome,
which indicates that age was not an essential factor in the
healing process. According to Estefan et al. 2016, revascu-
larization procedure can be implemented in any age range
[75]. However, younger age groups were better candidates
for revascularization procedure than older ones where their
enrolled patient’s age was from 9 to 18 years, and they con-
sidered older age starting from 14 years. Also, Jayadevan
et al. 2021 who assessed regenerative procedures following
traumatic dental injuries in an age range from 8 to 27 years,
that is a lot wider than the age range of the current study,
and didn’t find any significant impact of age on the healing
capacity between the two experimental groups [76]. In the
present study, the age range was from 13 to 30 and all the
candidates have nearly shown the same healing power and
their age would not have an impact on the healing power.
A likely explanation for these results could be attributed
to the adequate canal disinfection and bacterial eradication
which is the most important factor and the key to success
of REP [77] and inhibited the resorptive process [3]. Since
i-PRF has nearly the same composition as PRF but was
proven to release more growth factors and more leukocyte
concentrations, it could be concluded that it has the same
effect of inhibiting osteo/odontoclastogenesis as reported by
Kumar et al. [78] and Kargapour et al. [79] who found that
PRF membranes can inhibit the formation of osteoclasts.
It was shown that the expression levels of inflammatory-
related genes as TNF-a and IL-1b were significantly reduced
after treatment with liquid PRF [80]. These inflammatory
cytokines play important roles in a variety of signaling
cascades, such as the RANKL kappa B signaling pathway
which initiates osteo/odontoclastogenesis [26]. Moreover,
i- PRF induced great alkaline phosphatase activity, dentin
sialophosphoprotein, dentin matrix protein, and mRNA
expression of TGF-β, osteocalcin, PDGF, and type I col-
lagen [81] that stimulates the differentiation of osteoblasts
and the deposition of the mineral matrix [82].
Conclusions
Within the limitations of this study where a histologic
examination was not performed, the i-PRF revascularization
technique proved to be a successful REP in the treatment of
the IIRR. The arrest and progressive decrease of root canal
resorptive cavities volumetric size and the healing of the
associated periapical lesions. Reestablishing real regener-
ated pulp tissue after REP in the root canal of teeth with root
resorption needs a high level of evidence with large-scale
investigations.
Declarations 
Ethics approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
The study was approved by the Ethical Committee of the Faculty of
Medicine Fayoum University (R121).
Consent to participate  Informed consent was obtained from all indi-
vidual participants included in the study or from the parents of the
children included in the study.
Consent for publication  The authors affirm that the patient/parent/
guardian/ relative of the patient provided informed consent for publica-
tion of their clinical details and/or clinical images which was obtained
from them.
Conflict of interest  The authors declare no competing interests.
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