Case Report/Clinical Techniques
Histologic and Immunohistochemical Findings of a Human
Immature Permanent Tooth with Apical Periodontitis
after Regenerative Endodontic Treatment
Lishan Lei, MDS,*† Yuemin Chen, BDS,*† Ronghui Zhou, BDS,*† Xiaojing Huang, DDS, PhD,*†
and Zhiyu Cai, MDS*†‡
Abstract
Introduction: Specimens of human immature perma-
nent teeth after regenerative endodontic treatment
(RET) are sparse. This case report describes the histolog-
ic and immunohistochemical findings of tissue formed in
the canal space of a human immature permanent tooth
with apical periodontitis after RET. Methods: A patient
presenting with immature human permanent tooth
#29 with apical periodontitis underwent RET. At the
10-month follow-up visit, radiographic examination re-
vealed complete resolution of the periapical lesion,
marked narrowing of the apical foramen, increased
thickness of the canal walls, and minimal lengthening
of the root. Notably, the tooth regained pulp sensibility.
Tooth #29 was extracted for orthodontic reasons and
processed for histologic and immunohistochemical ex-
amination. Results: The canal space was filled with
newly formed cementumlike tissue, bonelike tissue,
and fibrous connective tissue. The apical closure, thick-
ness, and length increment of the root were caused by
the deposition of cementumlike tissue without dentin.
Furthermore, neurons and nerve fibers were observed
in the canal space; this observation was confirmed by
immunohistochemistry. Conclusions: Based on the
findings in the present case, after RET, the newly formed
tissues in the canal space of the human immature per-
manent tooth with apical periodontitis were primarily
fibrous connective tissue, cementumlike tissue, and
bonelike tissue. Nerve regeneration was identified. (J
Endod 2015;-:1–8)
Key Words
Apical periodontitis, cementumlike tissue, human imma-
ture permanent tooth, nerve regeneration, regenerative
endodontic treatment
From the *School and Hospital of Stomatology, and †Key Laboratory of Stomatology, Fujian Medical University, Fujian Province University; and ‡Department of Sto-
matology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
Address requests for reprints to Dr Xiaojing Huang, School and Hospital of Stomatology, Fujian Medical University, 246 Yangqiao Zhong Road, Fuzhou, Fujian
350002, China. E-mail address: hxiaoj@163.com
0099-2399/$ - see front matter
Copyright ª 2015 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.03.012
JOE — Volume -, Number -, - 2015
T he interest in regenerative endodontics has increased because of case reports with
successful outcomes (1, 2). A number of case reports and case series regarding the
regenerative endodontic treatment of human immature permanent teeth with pulp
necrosis or apical periodontitis have been published. Radiographically, many of
these cases have shown favorable results as evidenced by the resolution of apical
radiolucency, root lengthening, apical closure, and hard tissue deposition on the
canal walls (3, 4). In addition, the recovery of pulp sensibility has been observed in
a few cases (1, 2, 5–8). The newly formed soft tissue might be regenerated by pulp
tissue or periodontal ligament (PDL) tissue, whereas the hard tissue deposition
could be caused by the ingrowth of dentin, cementum, or bone (9). Histologic studies
in animal models (10–12) showed that the tissues growing in the canal space were
cementumlike or bonelike hard tissue and PDL-like connective tissue. However,
because only human histologic studies could directly answer the question of tissue iden-
tity after regenerative endodontic treatment in patients, samples obtained at rare oppor-
tunities are valuable for accumulating evidence of tissue identity. Recently, 5 case
reports described histologic findings after successful regenerative endodontic treat-
ment (RET) in humans (13–17). These reports showed that the tissue growing in
the pulp space was different (Table 1). Moreover, where these tissues come from
and whether nerve regeneration in the pulp space occurs after RET remain unknown.
The aim of this study was to describe histologically and immunohistochemically a hu-
man immature permanent mandibular premolar that initially had apical periodontitis
and then regained sensibility after RET. To our knowledge, this is the first histologic
and immunohistochemical study of a human immature permanent tooth after RET
that has positive responses to cold and pulp vitality tests similar to those of the adjacent
tooth.
Case Report
A 10-year-old girl was referred by a general dentist to the Department of Endodon-
tics and Operative Dentistry, School and Hospital of Stomatology, Fujian Medical Uni-
versity, Fuzhou, Fujian, China. The patient’s chief complaint was the presence of pain
during mastication for 2 weeks. The patient suffered from pain for 2 weeks before
visiting her general dentist. The general dentist made an opening to access tooth #30
based on the diagnosis of irreversible pulpitis. However, because the pain persisted,
the dentist referred this patient to our hospital. Clinical examination revealed extensive
caries in tooth #30, and the access point was kept open with a cotton pellet. Tooth #30
was not sensitive to percussion and palpation and did not have mobility. Tooth #29 was
Human Immature Permanent Tooth with RET 1
Case Report/Clinical Techniques

TABLE 1. Current Published Histologic and Immunohistochemical Reports of Regenerative Endodontic Treatment in Humans
Post-treatment
vitality Immunohistochemical
Authors Diagnosis Scaffold responses Histologic findings findings
Torabinejad Pulp necrosis and Platelet-rich Yes Collagen fibers, cells, and blood NA
et al, symptomatic apical plasma vessels in pulplike connective
2012 (17) periodontitis tissue. No odontoblastlike
cells could be observed in the
canal (only soft tissue in the
canal).
Shimizu Symptomatic Blood clot No Connective tissue, Strol-1–positive cells
et al, irreversible odontoblastlike cells and were observed in
2012 (16) pulpitis epithelial-like HERS. No the connective tissue
nervelike fibers and hard near the apical
tissue was formed in the canal. foramen.
Martin Pulp necrosis and Platelet-rich NA Cementoid/osteoid tissue and NA
et al, symptomatic apical plasma uninflamed fibrous
2013 (14) periodontitis connective tissue. No HERS or
odontoblastlike cells could be
observed in the canal.
Shimizu Pulpal necrosis and Blood clot NA Cementum- or bonelike tissue Positive immunoreactivity
et al, chronic apical and fibrous connective tissue. for BSP was observed,
2013 (15) abscess No pulplike tissue was present whereas DSP and
as characterized by the neurofilament
presence of polarized immunoreactivity were
odontoblastlike cells. negative.
Becerra Pulpal necrosis and Blood clot NA Connective tissue similar to that NA
et al, a chronic apical in the periodontal ligament
2014 (13) abscess and cementumlike or
bonelike hard tissue. No
tubulelike structures of
mineralized tissue or
odontoblastlike cells could be
observed in the canal.
NA, information not available.

free of caries but had dens evaginatus with a fractured occlusal tubercle.
Localized swelling and redness were present in the buccal mucosa fac-
ing its apex. This tooth was tender to percussion with class 2 mobility.
Pulp sensibility tests with an ice stick and an electric pulp test (EPT)
were performed on teeth #20, #28, #29, and #30. Positive responses
were elicited in teeth #20 and #28 but not in teeth #29 and #30. Peri-
odontal probing depths were within normal limits for all the teeth.
Radiographic examination (Fig. 1A) revealed that tooth #29 had an
incomplete apex and periapical radiolucency. After clinical and radio-
graphic examination, the diagnoses were as follows: tooth #29 had
pulpal necrosis with symptomatic apical periodontitis, and tooth #30
had pulpal necrosis. Root canal treatment was proposed for tooth
#30. For tooth #29, treatment options and procedures, including con-
ventional calcium hydroxide apexification, an artificial apical barrier
technique, and RET were explained to the parents and the child. RET
was finally chosen for the child, and informed consent was obtained.
First Treatment Visit
No anesthesia was administered initially to evaluate whether vital
tissue was present in the root canal of tooth #29. When the access cavity
was made under rubber dam isolation, a purulent hemorrhagic exudate
was discharged from the pulp chamber. Observation with a Zeiss sur-
gical microscope (Carl Zeiss Meditac Inc, Dublin, CA) confirmed the
absence of vital tissue in the pulp chamber and canal. Without mechan-
ical instrumentation, the pulp chamber and canal were gently irrigated
with 20 mL 1% sodium hypochlorite. Then, the canal was dried with
sterile paper points. Subsequently, a triple antibiotic paste that consisted
of a powder of 100 mg each of ciprofloxacin, metronidazole, and cefa-
clor mixed with 1 mL sterile water was placed into the apical portion of
the canal and filled to the level directly below the cementoenamel junc-
tion using a syringe under a microscope. The access cavity was tempo-
rized with 3 mm Cavit (3M ESPE, Seefeld, Germany) and 2 mm glass
ionomer (Fuji IX; GC, Tokyo, Japan). Tooth #30 received root canal
treatment; this tooth is not discussed further in this report.
Second Treatment Visit
The patient returned to the clinic 4 weeks later. The tooth was
asymptomatic with intact temporary fillings. Tooth #29 was not tender
to percussion or palpation. No mobility was noted. Local anesthesia was
administered with 2% lidocaine without a vasoconstrictor. After isola-
tion with a rubber dam, the temporary filling was removed, and no
sign of inflammatory exudate was observed. Then, the antibiotic paste
was gently flushed out of the canal with copious amounts of sterile
normal saline. Next, the canal was irrigated with 10 mL 17% EDTA so-
lution and dried with sterile paper points. Under a surgical microscope,
a sterile #35 K-file was introduced into the canal through the apical fo-
ramen with a push and pull motion to provoke bleeding from the peri-
apical tissue into the canal up to 3 mm below the cementoenamel
junction. A sterile moist cotton pellet was applied with gentle pressure
for 15 minutes to form a stable blood clot in the canal. The blood clot
was covered by a layer of CollaPlug (Zimmer Dental, Carlsbad, CA) and
then by a 3-mm thickness of a ProRoot mineral trioxide aggregate
(MTA) mixture (Dentsply Tulsa Dental Specialties, Tulsa, OK). A moist

2 Lei et al. JOE — Volume -, Number -, - 2015


Figure 1. (A) A preoperative radiograph of tooth #29 exhibiting incomplete formation of the root with periapical radiolucency. (B) A radiograph 6 months post-
operatively showing a slight increase the thickness of the canal walls and narrowing of the apical foramen. (C) Radiographs at the 10-month recall visit of tooth #29
showing a marked increase in the thickness of the canal walls and narrowing of the apical foramen. A slight root lengthening is also noticed. (D) An image of
extracted tooth #29.
cotton pellet was placed over the MTA, and the access cavity was sealed
with Cavit.
Third Treatment Visit
One week later, the tooth was asymptomatic. Cavit was removed
and replaced with a bonded resin restoration (Filtek Z350 XT; 3M
ESPE Dental Products, St Paul, MN). Follow-up visits were scheduled
at 3, 6, 9, 12, 18, and 24 months.
Follow-up Visits
At the 6-month follow-up visit, tooth #29 was asymptomatic and
not sensitive to percussion or palpation. The radiographic examination
revealed a slight increase in the thickness of the root canal walls
and a narrower apical foramen (Fig. 1B). When testing sensibility,
EPT (Parkell Inc, Farmingdale, NY) gave a positive response, whereas
no reaction was obtained with the cold test.
At the 10-month follow-up visit, tooth #29 remained asymptomatic
and was not sensitive to percussion or palpation. Marked narrowing of
the apical foramen and increased thickness of the canal walls of tooth
#29 were observed radiographically. A slight lengthening of the root was
also noticed (Fig. 1C). In addition, notably, a positive response was eli-
cited in tooth #29 by either the ice stick test or EPT, similar to the re-
sponses of teeth #28 and #20. At this period, for orthodontic reasons,
the mandibular second premolars were required to be extracted by the
treating orthodontist after a complete case study. With the permission of
the patient’s parents, we were allowed to process the extracted teeth for
histology. After extraction, teeth #29 (Fig. 1D) and #20 (used as the
control) were immediately fixed in 10% neutral buffered formalin
solution for histologic and immunohistochemical processing.
JOE — Volume -, Number -, - 2015
Case Report/Clinical Techniques
Histologic Procedure
After fixation, the teeth were demineralized in 10% EDTA
(pH = 7.4) for 6 months at room temperature. Subsequently, the sam-
ples were rinsed under running water for 4 hours followed by dehydra-
tion with ascending concentrations of ethanol. Then, the teeth were
deparaffinized in xylene, infiltrated, and embedded in paraffin. With
the microtome set at 4 mm, longitudinal serial sections were cut on a
buccolingual plane until the specimen was exhausted. Every fifth slide
was stained with hematoxylin-eosin and Masson trichrome for
screening purposes and for assessing the tissues formed in the canals.
The slides were observed under a light microscope.
Immunohistochemical Procedure
To detect the presence of odontoblasts and neural cells, antibodies
for nestin (Clone 2C1.3A11 [ab27053; Abcam, Cambridge, UK]) and
protein gene product (PGP) 9.5 (ab27053, Abcam) were used. PGP
9.5 is a neuron-specific protein that is widely distributed in both central
and peripheral neurons (18). Immunohistochemical staining was per-
formed using the streptavidin-biotin system (Santa Cruz Biotechnology,
Santa Cruz, CA) according to the manufacturer’s protocol. In brief, the
sections were cleared with xylene and then dehydrated in ethanol. After
antigen retrieval with 10 mmol/L sodium citrate buffer solution, endog-
enous peroxidase activity was blocked by 3% H2O2. The sections were
incubated with 10% normal goat serum and then with mouse anti-nestin
monoclonal antibody or rabbit anti–PGP 9.5 polyclonal antibody over-
night at 4 C. Samples of tooth #20 were used as positive controls,
whereas sections incubated with phosphate-buffered saline served as
negative controls. Then, the sections were incubated with secondary
biotinylated goat anti-mouse or anti-rabbit immunoglobulin G and
washed with phosphate-buffered saline. Finally, staining was completed
Human Immature Permanent Tooth with RET 3
Case Report/Clinical Techniques
by incubation with 3,3’-diaminobenzidine substrate (Vector Labora-
tories Inc, Burlingame, CA) for 5 minutes.
Histologic and Immunohistochemical Observations
Longitudinal sections of tooth #29 revealed that the tissues in the
canal space consisted of newly formed calcified tissue and fibrous con-
nective tissue interspersed with blood vessels (Fig. 2A–C). The new tis-
sue filled the canal space up to the coronal MTA (Fig. 2C). The newly
formed mineralized tissue on the canal walls was both cellular and acel-
lular cementumlike tissue (Fig. 2D), and many cementocytelike cells
were present in the cellular cementumlike tissue (Fig. 2D). The demar-
cation between the cementumlike tissue and canal dentin could be
easily recognized by the absence of dentinal tubules in the former
(Fig. 2D). Bonelike tissue with osteocytelike and osteoblastlike cells
(Fig. 2E) formed mineralized tissue islands in the middle portion of
the canal space (Fig. 2A and B). The canal dentin appeared to connect
directly to the cementumlike tissue (Fig. 2F). At the border of the un-
inflamed fibrous connective tissue, which was characterized primarily
by spindle-shaped fibroblasts and collagen fibers (Fig. 2C), collagen
bundles were inserted into the cementumlike (Fig. 2J) and bonelike tis-
sue (Fig. 2M) at right angles. The fibrous connective tissue in the apical
canal appeared to be an extension of the periodontal ligament (Fig. 2L).
Neurons and nerve fibers were observed in the newly formed tissue
(Fig. 2H); this observation was confirmed by PGP 9.5 immunoreactivity
(Figs. 2I and 3A–C). In contrast to the control group (tooth #20)
(Fig. 2G), no odontoblastlike cells could be observed histologically
and immunohistochemically in tooth #29 (Figs. 2D and 3E–G).
Discussion
The results of the present case showed that the tissue formed in the
canal space after RET consisted primarily of cementumlike tissue, bone-
like tissue, and fibrous connective tissue. The narrowing of the apical
closure and the increased thickness and length of the root were caused
by the deposition of cementumlike tissue. Based on the absence of a tu-
bulelike structure and negative immunoreactivity to nestin, the newly
formed mineralized tissue was not dentin. These findings were consis-
tent with those observed in animal studies (10–12) and previous
human case reports (13, 15). The cells that are able to promote
continued root growth include PDL stem cells (19), stem cells from
the apical papilla (SCAPs) (20), the Hertwig epithelial root sheath
(21), and bone marrow mesenchymal stem cells transplanted into
the canal space (22). Histologically, the fibrous connective tissue in
the apical canal appeared to be an extension of the PDL. Additionally,
PDL-like fibers were inserted into the cementumlike and bonelike tissue
at right angles as Sharpey’s fibers. Therefore, in this case, the cemen-
toid/osteoid tissue in the pulp space might be generated by cemento-
blasts/osteoblasts that differentiated from the PDL. Because no nestin
immunoreactivities or nestin-positive cells were identified in the canal
space, pulp tissue regeneration was not present. Our observation of the
absence of pulp tissue is in agreement with most previous studies. How-
ever, recent histologic evidence from 2 case reports suggested that
regenerated pulplike tissue might be in the canal space after RET
(16, 17). Theoretically, the infection duration and severity, the
involved microbial species, the RET variables, the host immunity, and
the open apex size all may play a role in the outcome of tissue
regeneration.
PGP 9.5 is advantageous for immunohistochemical analyses when
studying the innervation of hard tissues because it is not affected by
demineralization procedures (23). Dense PGP 9.5 immunoreactivity
has been reported in the distribution of nerve fibers in human radicular
dental pulp, and the usefulness of the antibody directed against PGP
4 Lei et al.
9.5 for the identification of nerve fibers in human teeth has been
confirmed (24).
To our knowledge, this is the first histologic and immunohisto-
chemical evidence in the dental literature that shows that nerve tissue
can be regenerated in a human immature permanent tooth with previ-
ous necrotic pulp and apical periodontitis. Our clinical examination re-
vealed continuous recovery of the sensibility of the tooth after RET.
Positive responses to tooth sensibility tests have been reported by a
few previous case studies (1, 2, 5–8). In these cases, tooth sensibility
recovery was observed from 5 ½ months to 2 years postoperatively. A
histologic study was conducted in only 1 of these cases without
findings of regenerated nerve tissue (17). In this case, the presence
of nerve tissue was identified by histologic observation as well as immu-
nochemical investigation with PGP 9.5. The results confirmed the exis-
tence of regenerated neurons and nerve fibers in the canal space and
apical region, indicating the feasibility of nerve regeneration after
RET. Nerve regeneration may be attributed to many mechanisms.
One possible mechanism postulates that stem cells might differen-
tiate from the PDL. Human PDL stem cell subpopulations have been re-
ported to express the markers of undifferentiated neural crest cells
(nestin, Slug, and p75) and to exhibit the potential to differentiate
into neurogenic lineages (25–27).
Another hypothesized mechanism depends on the survival of
dental pulp stem cells (DPSCs) from residual vital apical pulp tissue.
In mature teeth, some vital pulp tissue might remain despite the pres-
ence of a periradicular lesion (28). DPSCs have the potential to differ-
entiate into neuronal cells in vitro (29) and can induce axon guidance
(30). In addition, DPSCs can produce a series of neurotrophic factors,
including nerve growth factor, glial cell line–derived neurotrophic fac-
tor, and brain-derived neurotrophic factor (31–33). Human DPSCs that
were implanted into the developing brain of embryonic chicken
exhibited neuronal morphology and were positive for neuronal
markers (29). All these facts support the idea that DPSCs might have
initiated the regeneration of nerve tissue.
The third possible mechanism relies on SCAPs. In the case of an
immature tooth with apical periodontitis, SCAPs residing in the apical
papilla likely survived the infection (34). Moreover, SCAPs have been
shown to stain positive for several neural markers (35). SCAPs might
be derived from neural crest cells or at least associated with neural crest
cells analogous to dental stem cells such as DPSCs and stem cells from
human exfoliated deciduous teeth (SHED) that have been shown previ-
ously to possess neurogenic potential (36, 37).
The fourth possible mechanism relies on bone marrow mesen-
chymal stem cells. During the induction of periapical bleeding by irri-
tating the periapical tissues, mesenchymal stem cells from the bone
marrow may be transplanted into the root canal. Bone marrow mesen-
chymal stem cells can differentiate into neurons and astrocytes under
appropriate conditions (38). It has been shown that transplanted
bone marrow mesenchymal stem cells into the injured spinal cord of
rats could differentiate into neurons and astrocytes and repair spinal
cord ischemia injury (39).
The fifth possible mechanism is that the pulp canal likely received a
collateral reinnervation by the sprouting or ingrowth of neighboring ipsi-
lateral nerves, similar to the reinnervation of replanted and autotrans-
planted immature teeth after surgery. Several studies have reported that
the reinnervation, tooth sensitivity restoration, and prognosis of the
replanted teeth are favored if the tooth infection is controlled with an
open apex and rapidly regained revascularization (40–42). In addition,
nerve fibers are known to regenerate after the transection of the
inferior alveolar nerve and to grow into the tooth pulp by the sprouting
and ingrowth of intact nerves in adjacent tissues (43, 44). However, the
underlying mechanism of this action needs further investigation.
JOE — Volume -, Number -, - 2015
 Case Report/Clinical Techniques

Figure 2. (A and B) The section passing approximately at the center of the root canal of tooth #29; the newly formed tissue consists of connective tissue, miner-
alized tissue deposited on the canal walls, and mineralized tissue islands in the canal space (hematoxylin-eosin; original magnification, 40). (C) A detailed view of

JOE — Volume -, Number -, - 2015 Human Immature Permanent Tooth with RET 5
Case Report/Clinical Techniques

Figure 3. Immunohistochemical staining for PGP 9.5 and nestin. (A) A low-magnification view of tooth #29; positive immunoreactivity for PGP 9.5 is observed in
the newly formed connective tissue (original magnification, 100). (B and C) A high-magnification view of the area indicated by the rectangle in A (original
magnification, 400). (D) Section with PGP 9.5 immunoreactivity similar to A in the positive control group (tooth #20) (original magnification, 200). (E)
A low-magnification view of tooth #29; no nestin immunoreactivity is detected (original magnification, 40). (F) A detailed view of the right rectangle in E (original
magnification,  200). (G) A high-magnification view of the area indicated by the rectangle in E (original magnification, 400). (H) Nestin immunoreactivity in
the positive control group (tooth #20); intense immunoreactivity for nestin is exhibited in odontoblasts (original magnification, 400).

Different concentrations of NaOCl ranging from 1.25%–5.25%
were used in previous case studies (45). However, high concentrations
of NaOCl could have a profound negative effect on the survival and differ-
entiation of stem cells (46, 47). Several studies have shown that dentin
conditioning with 5.25% NaOCl prevented the differentiation of SHED
and DPSCs into odontoblastlike cells (48, 49). In addition, previous
studies have found no significant difference in the antibacterial effects
of 1%, 2.5%, and 5.25% NaOCl (50, 51). Thus, the use of a low
concentration of NaOCl in RET is rational. Moreover, a previous study
found that EDTA could effectively release growth factors from human

the upper rectangle in A; the regenerated soft tissue is uninflamed fibrous connective tissue characterized by spindle-shaped fibroblasts and collagen fibers inter-
spersed with blood vessels (*). This tissue fills the canal space up to the coronal MTA (yellow arrow) (original magnification, 100; inset, 400). (D) A detailed
view of the lower rectangle in A; the regenerated hard tissues on the canal walls are cellular and acellular cementumlike tissues. Many cementocytelike cells (black
arrow) are present in the cellular cementumlike tissue (original magnification, 200). (E) A high-magnification view of the mineralized tissue islands in the canal
space; the mineralized tissue islands are bonelike tissue with osteocytelike (white arrow) and osteoblastlike cells (blue arrow). (F) A high-magnification view of
the square in D; the canal dentin appears to show a direct junction with cementumlike tissue. Fibrous tissues resembling the PDL (black arrow) are observed
transversely in the space between cellular and acellular cementumlike tissues (original magnification, 400). (G) A detailed view of a similar section of the control
(tooth #20); this section is characterized by a normally aligned odontoblast layer, clearly recognizable dentinal tubules and a central pulp rich in neurovascular
structures (original magnification, 200). Ac, acellular cementum; Cc, cellular cementum; De, dentin. (H) A high-magnification view of the lower rectangle in B:
neurons (white arrow) and nerve fibers (black arrow) are identified (original magnification, 400). (I) A high-magnification view of the section similar to H; the
presence of neurons and nerve fibers is confirmed (immunohistochemical staining; original magnification, 400). (J) A high-magnification view of the upper
rectangle in K; the collagen bundles are inserted into the cementumlike tissue at right angles (original magnification, 400). (K–N) Sections similar to 2A
and 2B (Masson trichrome stain; original magnification, 40). (L) A detailed view of the right rectangle in N; the fibrous connective tissue in the apical canal
appears to be an extension of the PDL. The PDLs were inserted perpendicularly into the cementum (original magnification, 200; inset, 400). (M) A high-
magnification view of the upper rectangle in N; the collagen bundles are inserted into the bonelike tissue at right angles (original magnification, 400). Cc, cellular
cementum.

6 Lei et al. JOE — Volume -, Number -, - 2015


dentin (52–54), which might promote the development of odontoblast
proliferation after RET (55, 56). Therefore, in this case, we used 1%
NaOCl followed by EDTA for irrigation to preserve potential stem cells.
Conclusion
Based on the findings in the present case, after RET, the newly
formed tissues within root canals of the human immature tooth with api-
cal periodontitis were fibrous connective tissue, cementumlike tissue,
and bonelike tissue. The continued root development was caused by
the deposition of cementumlike tissue, and nerve regeneration was
identified.
Acknowledgments
Lishan Lei and Yuemin Chen contributed equally to this study.
Supported by the Fujian Province Science and Technology
Project of China (grant no. 2012Y0029) and Young and Middle-
aged Backbone Talents Training Project of Health System in Fujian
Province (grant no. 2014-ZQN-ZD-21).
The authors deny any confiicts of interest related to this study.
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JOE — Volume -, Number -, - 2015