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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2014  |  Volume : 32  |  Issue : 2  |  Page : 172-175

Maturogenesis by revascularization in an infected immature permanent tooth

1 Department of Pedodontics, Ibn Sina National Medical College, Jeddah, Kingdom of Saudi Arabia
2 Department of Pedodontics and Preventive Dentistry, People's Dental Academy, Bhopal, Madhya Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Rajasthan Dental College, Jaipur, Rajasthan, India
4 Department of Pedodontics and Preventive Dentistry, Jaipur Dental College, Jaipur, Rajasthan, India

Date of Web Publication17-Apr-2014

Correspondence Address:
Vanka Amit
Department of Pedodontics, Ibn Sina National Medical College, Jeddah, Kingdom of Saudi Arabia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.130992

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Root canal treatment in teeth with incomplete root formation is a challenge. A case of maturogenesis in an immature infected tooth along with probable factors needed for success is discussed. Although clinical and radiographic evidence points to healing and root development, the long-term prognosis and the behavior of tissue occupying the canal space needs further investigation before the procedure can be adopted into routine clinical practice.

Keywords: Immature teeth, maturogenesis, revascularization

How to cite this article:
Amit V, Jain A, Nayak UA, Bhat M. Maturogenesis by revascularization in an infected immature permanent tooth. J Indian Soc Pedod Prev Dent 2014;32:172-5

How to cite this URL:
Amit V, Jain A, Nayak UA, Bhat M. Maturogenesis by revascularization in an infected immature permanent tooth. J Indian Soc Pedod Prev Dent [serial online] 2014 [cited 2022 Jun 25];32:172-5. Available from: https://www.jisppd.com/text.asp?2014/32/2/172/130992

   Introduction Top

While a young permanent tooth with a wide apical foramen may sometimes recover from a traumatic injury by re-establishing blood flow, severe impact destroys the pulp vessels at the apical foramen and leads to pulp necrosis. [1] When teeth with incomplete root formation suffer pulp necrosis, the root development ceases and apical closure cannot be achieved. Root canal treatment at this time is a significant challenge; due to the size of the canal, the thin and fragile dentin walls and the large open apex. [2] Traditionally such cases have been treated with prolonged calcium hydroxide to induce the formation of hard tissue barrier. [3] Several studies have also researched mineral trioxide aggregate (MTA) and suggested that its placement as an apical plug is a predictable and reproducible clinical procedure. [2],[4]

As early as 1961, in a series of experimental investigations in dogs and human beings it was found that tissue formations could take place in the absence of pulp if the empty canal was filled with only blood from the periapical area. [5] It has also been shown that under certain conditions revascularization occurs in young teeth that have been traumatically avulsed, leaving a necrotic but uninfected pulp. [6] Presented here is a case of maturogenesis of the root inspite of presence of periapical infection.

   Case Report Top

The case we presented here is about a 10-year-old Indian girl who reported to the Department of Pedodontics and Preventive Dentistry with pain in the lower right back tooth region. The medical history was non-contributory. The mandibular first premolar (tooth no. 44) was found to be tender on percussion, with slightly increased mobility and pain on palpation in the associated gingiva. History of laceration of lip and subsequent "pain in the tooth for a few days after falling from bicycle 2 years back" was the only history elicited. The tooth did not respond to the electric pulp test. Radiographically, the premolar had diffuse periapical radiolucency, with widened periodontal ligament (PDL) space and incomplete root formation [Figure 1]a. The occlusal and proximal surfaces of the tooth were intact with no carious lesions diagnosed either clinically or radiographically. No signs of vertical fracture or presence of occlusal tubercle were found. With the diagnosis of a periapical abscess being made, endodontic treatment was initiated. In the first appointment emergency access opening was made without local anesthesia to establish drainage. The canal was explored to assess the presence of remnants of pulp tissue in the canal. Frank pus was encountered with no sensation even when instrumented slightly beyond working length. Access cavity was followed by gentle irrigation with 5.25% hypochlorite then 17% ethylenediaminetetraacetic acid (EDTA) followed by saline. The width of apex was wide enough to allow size 80 k file to freely pass into the periapical area. After drying canals with paper points, creamy mix of 1:1:1 ciprofloxacin (Ranbaxy laboratories) Metronidazole (Nicholas Piramal, India) and cefaclor (Ranbaxy laboratories) paste with sterile water was introduced into the canal using lentulospiral (Dentsply Maillefer) mounted on reduction gear handpiece until the level of cementoenamel junction (CEJ) followed by temporization by cavit.

At the next appointment 3 weeks later, anesthesia was achieved using 2% lignocaine without vasoconstrictor. The antibiotic paste was irrigated out using copious irrigation with saline. After drying with paper points, bleeding was induced into the canal using a sterile 20 size K-file that allowed for free passage into the periapical region without touching the walls of apical foramen. The bleeding was controlled using sterile cotton pellet just below the CEJ [Figure 2]a. Grey MTA (Angelus) was carefully placed above the blood clot up to the level of the CEJ [Figure 2]b. The access was sealed with a moist cotton pellet and cavit. At 2 days later, cavit was replaced with composite resin restoration (Z250 Filtek; 3M ESPE).

During the 18 months follow-up, the patient remained asymptomatic. The tooth responded negatively to the pulp tests at all the visits. Nevertheless, the radiographs demonstrated evidence of periradicular bone healing, partial regeneration of PDL space and root development when compared with pre-operative radiographs [Figure 1]b and c.
Figure 1:

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Figure 2:

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   Discussion Top

Treatment of immature pulpless teeth has always presented an enigma to the clinician. Surgical endodontic procedure to seal the wide-open blunderbuss apical opening has several disadvantages such as compromised crown root ratio in an immature tooth and failure to achieve cooperation, particularly in a child.

Prolonged contact with calcium hydroxide leads to a significant decrease in the intrinsic properties of exposed dentin, which when coupled with repeated use of root canal irrigants such as sodium hypochlorite, results in further weakening of the dentin and renders the tooth more prone to fractures. [7]

While MTA does overcome some of the problems associated with calcium hydroxide, including reinforcing the thin walls on the apical portion, it is incapable of increasing thickness of dentin. Continued physiological root development (a process also termed as maturogenesis) and not just closure of root apex (apexogenesis) [8] along with thickening of the root canal walls are the greatest advantages revascularization of pulp offers. In the presented case, root development was significant, but the thickening of root canals was lacking, a finding consistent with some of the responses observed in a previous case series. [9]

Disinfection of the canal has been described as the key factor to create an environment conducive to revascularization. [10] The use of irrigants such as chlorhexidine in higher concentration may affect the viability of the cells involved in the regenerative process and hence was not used in the presented case. The use of EDTA is thought to remove the smear layer and encourage habitation of root canal walls by viable cells. [11]

While some cases have used calcium hydroxide as intracanal medicaments, [12] several others have used a combination of ciprofloxacin, metronidazole and minocycline. [13],[14] With reports suggesting tooth discoloration is associated with the use of minocycline in the presented case it was replaced with cefaclor. Besides being effective, no discoloration of the tooth was observed. [15]

The presence of a suitable scaffold is one of the prerequisites of regenerative procedures. The blood clot induced during this procedure constitutes a fibrin pathway for migration of cells. [16] The process of inducing bleeding by manipulation of perapical tissues is associated with delivery of mesenchymal stem cells into the root canal systems, at higher levels than those in the systemic blood. [16] Thus, a niche for these stem cells appears to be present in the apical papilla region and the cells have been termed as stem cells from apical papilla. However, prolonged infection may eventually lead to a total necrosis of the pulp and apical papilla. [17] Maturogenesis would then be unlikely thus at least partially explaining some of the failures associated with the procedure. In vitro results show that MTA helps in proliferation and migration of human mesenchymal stem cells, enhancing the process of tissue growth in the canal. [18]

The size of the apical opening has been described as another deciding factor [19] with successful revascularization being associated with 1 mm or more mesiodistal width, as was demonstrated from the presented case. Lesser width can hamper the in growth of vital tissue leading to failure. It is also important to use local anesthetic without vasoconstrictor, while inducing bleeding, to promote the flow of blood into the canal. [20]

During the follow-up period, the tooth showed no response to the sensitivity cold and electric tests. The absence of a positive response could be because the tissue that invaginated into the canal space was probably not innervated [21] or may not be pulp tissue in the proper sense. The nature of tissue occupying the pulp space has been a matter of speculation. It has generally been described as a cell rich, well vascularized connective tissue and an extension from the periapical tissue. [22] The nature of hard tissue deposited has also been described to be intracanal cementum (IC), dentin-associated mineralized tissue and bony islands. The IC may also form a bridge at the apex, in the apical third or mid third of the canal. [23] Thus, it appears to be imperative that further research be directed towards factors that determine the lineage these mesenchymal stem cells get differentiated into. While it is desirable that these stem cells differentiate into odontoblasts and hence lay down dentin, in vivo reports have not provided precise information about a hard tissue with the classical pulp-odontoblast-dentin relationship. [24]

   Conclusion Top

Revascularization leading to maturogenesis is possible. While root development and hard tissue deposition takes place, the predictability of the procedure, the type of differentiation stem cells undergo and the eventual type of hard tissue laid down is still not clear. The long-term effects of this procedure require a thorough evaluation before it can be recommended as part of routine treatment modality in immature pulpless teeth.

   References Top

1.Yu C, Abbott PV. An overview of the dental pulp: Its functions and responses to injury. Aust Dent J 2007;52:S4-16.  Back to cited text no. 1
2.Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: A prospective study. Int Endod J 2007;40:186-97.  Back to cited text no. 2
3.Shah N, Logani A, Bhaskar U, Aggarwal V. Efficacy of revascularization to induce apexification/apexogensis in infected, nonvital, immature teeth: A pilot clinical study. J Endod 2008;34:919-25.  Back to cited text no. 3
4.Damle SG, Bhattal H, Loomba A. Apexification of anterior teeth: A comparative evaluation of mineral trioxide aggregate and calcium hydroxide paste. J Clin Pediatr Dent 2012;36:263-8.  Back to cited text no. 4
5.Ostby BN. The role of the blood clot in endodontic therapy. An experimental histologic study. Acta Odontol Scand 1961;19:324-53.  Back to cited text no. 5
6.Skoglund A, Tronstad L, Wallenius K. A microangiographic study of vascular changes in replanted and autotransplanted teeth of young dogs. Oral Surg Oral Med Oral Pathol 1978;45:17-28.  Back to cited text no. 6
7.Andreasen JO, Munksgaard EC, Bakland LK. Comparison of fracture resistance in root canals of immature sheep teeth after filling with calcium hydroxide or MTA. Dent Traumatol 2006;22:154-6.  Back to cited text no. 7
8.Weisleder R, Benitez CR. Maturogenesis: Is it a new concept? J Endod 2003;29:776-8.  Back to cited text no. 8
9.Chen MY, Chen KL, Chen CA, Tayebaty F, Rosenberg PA, Lin LM. Responses of immature permanent teeth with infected necrotic pulp tissue and apical periodontitis/abscess to revascularization procedures. Int Endod J 2012;45:294-305.  Back to cited text no. 9
10.Thibodeau B, Trope M. Pulp revascularization of a necrotic infected immature permanent tooth: Case report and review of the literature. Pediatr Dent 2007;29:47-50.  Back to cited text no. 10
11.Trevino EG, Patwardhan AN, Henry MA, Perry G, Dybdal-Hargreaves N, Hargreaves KM, et al. Effect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. J Endod 2011;37:1109-15.  Back to cited text no. 11
12.Cehreli ZC, Isbitiren B, Sara S, Erbas G. Regenerative endodontic treatment (revascularization) of immature necrotic molars medicated with calcium hydroxide: A case series. J Endod 2011;37:1327-30.  Back to cited text no. 12
13.Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200.  Back to cited text no. 13
14.Gelman R, Park H. Pulp revascularization in an immature necrotic tooth: A case report. Pediatr Dent 2012;34:496-9.  Back to cited text no. 14
15.Dabbagh B, Alvaro E, Vu DD, Rizkallah J, Schwartz S. Clinical complications in the revascularization of immature necrotic permanent teeth. Pediatr Dent 2012;34:414-7.  Back to cited text no. 15
16.Lovelace TW, Henry MA, Hargreaves KM, Diogenes A. Evaluation of the delivery of mesenchymal stem cells into the root canal space of necrotic immature teeth after clinical regenerative endodontic procedure. J Endod 2011;37:133-8.  Back to cited text no. 16
17.Huang GT, Sonoyama W, Liu Y, Liu H, Wang S, Shi S. The hidden treasure in apical papilla: The potential role in pulp/dentin regeneration and bioroot engineering. J Endod 2008;34:645-51.  Back to cited text no. 17
18.D'Antò V, Di Caprio MP, Ametrano G, Simeone M, Rengo S, Spagnuolo G. Effect of mineral trioxide aggregate on mesenchymal stem cells. J Endod 2010;36:1839-43.  Back to cited text no. 18
19.Kling M, Cvek M, Mejare I. Rate and predictability of pulp revascularization in therapeutically reimplanted permanent incisors. Endod Dent Traumatol 1986;2:83-9.  Back to cited text no. 19
20.Ding RY, Cheung GS, Chen J, Yin XZ, Wang QQ, Zhang periodontitis: A clinical study. J Endod 2009;35:745-9.  Back to cited text no. 20
21.Soares Ade J, Lins FF, Nagata JY, Gomes BP, Zaia AA, Ferraz CC, et al. Pulp revascularization after root canal decontamination with calcium hydroxide and 2% chlorhexidine gel. J Endod 2013;39:417-20.  Back to cited text no. 21
22.Shimizu E, Jong G, Partridge N, Rosenberg PA, Lin LM. Histologic observation of a human immature permanent tooth with irreversible pulpitis after revascularization/regeneration procedure. J Endod 2012;38:1293-7.  Back to cited text no. 22
23.Wang X, Thibodeau B, Trope M, Lin LM, Huang GT. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization procedure of immature dog teeth with apical periodontitis. J Endod 2010;36:56-63.  Back to cited text no. 23
24.Andreasen JO, Bakland LK. Pulp regeneration after non-infected and infected necrosis, what type of tissue do we want? A review. Dent Traumatol 2012;28:13-8.  Back to cited text no. 24


  [Figure 1], [Figure 2]

This article has been cited by
1 Regenerative Endodontic Therapy: A Data Analysis of Clinical Protocols
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[Pubmed] | [DOI]


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