Pulp Revascularization Research Articles

Success of Revascularization of Pulp in Necrotic Maxillary Anterior Immature Permanent Teeth

Objectives: The purpose of the study was to examine efficacy of this procedure in necrotic immature permanent teeth. Methods: Forty patients were enrolled for pulp revascularization procedure by disinfecting the root canal with triple antibiotics paste for one to two weeks, followed by creating the blood clot, sealing the canal orifice with mineral trioxide aggregate as sealing material. Patients were recalled periodically for up to twenty four months. Results: Clinical evaluations demonstrated no adverse effects, during follow up 35 patients were asymptomatic, five cases of periapical periodontitis showed disappearance of sinus tract, on radiographic assessment there was progressive resolution of periapical radiolucency within first three-six months, the electric pulp test on sixth week demonstrated positive response, on radiographic evaluation there was progressive root length and thickness and continued root growth on six –twelfth months. Conclusion: Revascularization is a safe and efficacious method of dental pulp regeneration in this study. Keywords: Necrosis, Immature Permanent Teeth, Revascularization.

New advances in vital pulp therapy and pulp regeneration for the treatment of pulpitis: from basic to clinical application

In recent years, great progress has been made in research on the treatment of pulpitis, mainly due to the rapid development of basic and clinical researches in this field, and some achievement from basic research has been applied in clinical practice. Advances in the diagnostic methods for pulpitis can help the clinicians to recognize the true state of pulpitis more accurately and to adopt the corresponding treatment methods including indirect/direct pulp capping, pulpotomy, pulp regeneration and root canal therapy. The new theory of pulpitis diagnosis and the studies on immune defense, repair function of dental pulp and new pulp capping materials have significantly improved the success rate of vital pulp therapy. For diffuse coronary pulpitis or radicular pulpitis, which is difficult to achieve vital pulp therapy successfully, methods of pulp revascularization, cell homing and pulp stem cells-mediated pulp regeneration can also be used as treatment options in addition to root canal therapy. The present article focuses on the research progress on pulpitis treatments and related clinical transformation practices, in order to provide reference on vital pulp therapy and pulp regeneration for clinicians.

Pulp Revascularization and Regeneration: Differences, Utilization, and Outcome

Microbial, mechanical, physical, and chemical factors are strong enough to endanger tooth pulp, resulting in alterations and inflammation of its vasculature, and causing intolerable pain. Clinical and technical management of diseases of these tissues is oftentimes very difficult due to the vastly varied anatomical nature of the pulpal space. Root canal treatment has been used to scavenge the diseased pulp and allow healing of the supporting tissues. In a small proportion of teeth, the creation of the apical root structure Hertwig’s Epithelial Root Sheath may not be completed (causing an open apex) because of trauma or breach of the pulp by caries. In these scenarios, alternative techniques have been found, which regenerate a functional pulp tissue optimally. Regenerative endodontic procedures are biologically based techniques devised for predictable replacement of injured, infected, or missing structures with live viable tissues that restore the normal physiologic functions of the pulpdentine complex. Pulp revascularization is generally described as re-introduction of vascularity in the root canal system. Pulp regeneration, on the contrary, has not been accurately defined. Even though blood vessels are necessary components of dental pulp, pulpal regeneration is regarded incomplete without an odontoblastic layer bordering the dentin-pulp interface. Although the interactions with human pulp derived stem cells are still vague, it is suspected that conventional pulpal cells that resist infection can grow rapidly under the impact of Hertwig’s epithelial root sheath even during the inflammation stage; generating odontoblasts which has the ability to give rise to a tubular dentin, triggering apexogenesis. It is understood that similar and consistent outcomes in the endodontics are not always achieved. The pace of apex maturogenesis differs due to distinctive conditions of each case. A possibility of chronic necrosis my strip the pulpal tissue of remnants of viable cells and may lead to reduced capabilities to regenerate.

Hypoxia-Mediated Upregulation of Semaphorin 3A during Pulp Revascularization

Semaphorin 3A could be involved in angiogenesis and also enhanced bone formation was investigated in many researches. In our current study, we firstly investigated that canal obliteration might be present in some regenerative endodontic procedures cases clinically. After the establishment of the model of apical periodontitis in the maxillary first molars of rats, pulp revascularization was performed in mesial root canal. Histological sections showed that most of the tissues growing into the root canal were not real pulp tissue, but cementoid, osteoid and periodontal-like membrane. Moreover, we detected that the expression of Semaphorin 3A increased in the mesial root canal. When we used CoCl2 to induce hypoxic environment, the expression of genes and proteins, Hypoxia inducible factor-1α, Vascular endothelial growth factor, and Semaphorin 3A in dental pulp stem cells were both upregulated. In conclusion, hypoxia mediated the high expression of Semaphorin 3A in DPSC might be involved tissue regeneration during pulp vascularization.

Pulp Revascularization: Future Therapy of Tooth with Open Apex

Introduction: The endodontic management of necrotic permanent immature teeth is a challenge for the practitioner. These teeth are treated by apexification. However, because of the complications associated with this treatment, researchers have developed other therapies. Currently, a new technique called pulp revascularization has emerged. This technique allows the continuation of root completion thanks to a healthy tissue newly formed at the intra root canal level. Material and method: A literature search of articles dealing with pulp revascularization of immature permanent teeth was conducted using two types of search strategy, a literature search using keywords on databases and then a manual “bottom-up” search of references of previously identified articles. Results: 112 articles were identified based on inclusion and exclusion criteria. Discussion: This work showed that pulp revascularization is a new therapy that aims to restart root development on an immature permanent tooth. It is based on the principle of tissue engineering and uses the differentiation potential of stem cells. Conclusion: Currently, the literature values revascularization as it allows root development, sidewall thickening, apical closure and a decrease in periapical lesion and ensures a good sealing. Clinical and radiographic success rates appear to be encouraging, except that factors influencing treatment must be taken into consideration.

Revascularisation versus apexification for treatment of immature teeth based on periapical healing and root development: A systematic review and meta-analysis.

Immature necrotic teeth are frequent findings in adolescents that may lead to thin root walls and open apexes. The absence of an apical stop becomes a challenge for endodontic treatment because it is difficult or impossible to seal the immature root canal with conventional endodontic techniques. Revascularisation therapy (RET) may be more suitable for the treatment of immature necrotic teeth. However, clinicians are still more inclined to choose apexification (AP) when considering the predictability of treatment results. The literature was searched via PubMed/MEDLINE and the Cochrane Library, Web of Science data from June, 2001 to September, 2020 and randomised clinical trials were selected that compared RET with AP for the treatment of immature necrotic teeth assessing clinical and radiographic results. A total of 556 articles were retrieved, though only five studies were included. There were no differences in the periapical healing rate, overall effective rate/invalid rate, or apical closure rate between RET and AP. The root length was significantly increased in the RET group compared with the AP group quantitatively (pooled difference in means=1.28, 95% CI: [1.08, 1.48], Z=12.69, P<0.00001) and qualitatively (pooled RR=4.12, 95% CI: [2.44, 6.97]), Z=5.28, P<0.00001). The effective rate of root thickness was significantly increased in the RET group compared with the AP group (pooled RR=22.63, 95% CI: [6.08, 84.26]), Z=4.65, P<0.00001). Both RET and AP were effective options regarding the healing of periapical periodontitis or the closure of open apices. Pulp revascularisation is more effective for root elongation and thickening without higher risk of overall invalid treatment.

Functional Dental Pulp Regeneration: Basic Research and Clinical Translation.

Pulpal and periapical diseases account for a large proportion of dental visits, the current treatments for which are root canal therapy (RCT) and pulp revascularisation. Despite the clinical signs of full recovery and histological reconstruction, true regeneration of pulp tissues is still far from being achieved. The goal of regenerative endodontics is to promote normal pulp function recovery in inflamed or necrotic teeth that would result in true regeneration of the pulpodentinal complex. Recently, rapid progress has been made related to tissue engineering-mediated pulp regeneration, which combines stem cells, biomaterials, and growth factors. Since the successful isolation and characterisation of dental pulp stem cells (DPSCs) and other applicable dental mesenchymal stem cells, basic research and preclinical exploration of stem cell-mediated functional pulp regeneration via cell transplantation and cell homing have received considerably more attention. Some of this effort has translated into clinical therapeutic applications, bringing a ground-breaking revolution and a new perspective to the endodontic field. In this article, we retrospectively examined the current treatment status and clinical goals of pulpal and periapical diseases and scrutinized biological studies of functional pulp regeneration with a focus on DPSCs, biomaterials, and growth factors. Then, we reviewed preclinical experiments based on various animal models and research strategies. Finally, we summarised the current challenges encountered in preclinical or clinical regenerative applications and suggested promising solutions to address these challenges to guide tissue engineering-mediated clinical translation in the future.

Apice closure in Pulp Revascularization Therapy. Case report and literature review

Background: Endodontic Regenerative Procedures, especially pulp revascularization therapy, have become a real option for the treatment for immature permanent teeth with open apices. This sort of approach has saved many teeth that otherwise would have been extracted. The technique is simple and effective, and can be accomplished by any odontologist. Objective: This article aimed to make a literature review to give support for a case report of an Endodontic Regenerative Procedure of a twelve-year-old male patient with immature open apice of tooth 21. Methodology: Articles were researched concerning pulp revascularization to reach root end formation. On line searches were accomplished, whose database include BVS/BIREME, Web of Science, PUBMED Central, Science Direct, Higher Level Personnel Improvement Coordinator (CAPES), The Cochrane Library, and PROSPERO). Results: the articles researched showed that Endodontic Regenerative Procedures are efficient in stimulating root end formation. The case report described matched the results offered by the articles, showing an immature open apice tooth that had its root end completely formed after pulp revascularization therapy. Conclusion: Pulp revascularization therapy is an efficient and practical treatment for immature teeth with open apices.

Evaluation of The Periapical Healing Following Pulp Revascularization Using Injectable PRF VS nonsurgical Root Canal Treatment in Mature Permanent Teeth with periapical periodontitis. A Clinical Study

Aim:the aim of the current study was to evaluate the effect of injectable platelet rich fibrin (i-PRF) revascularization technique VS conventional endodontic treatment on the periapical healing of mature permanent teeth with periapical periodontitis. Materials and Methods: A total of 30 patients with apical periodontitis related to permanent central incisors were included in the study. The control group (n=15) has undergone conventional root canal treatment using crown down technique on 2 visits with calcium hydroxide intracanal dressing in between visits and obturation was done using cold lateral compaction technique. The intervention group (n=15) has undergone regenerative procedures. Regenerative protocol was carried out using 1.5% sodium hypochlorite irrigation and DAP intracanal medicament for 3 weeks. At the second visit, i-PRF was prepared and injected inside the root canal. The orifice was sealed with MTA followed by double sealing of the access by glass ionomer and composite-resin restoration. Clinical and radiographic evaluation was done for 1, 3, 6, 9, and 12 months, and CBCT imaging was done after 12- month follow-up period. Results: The i-PRF group recorded more decrease in the lesion size than the control group. However, the difference was not statistically significant yet, there was a highly significant statistical difference between the preoperative and postoperative measurements with great lesion size reduction within the i-PRF group Conclusion: i-PRF revascularization is an effective treatment of apical periodontitis in permanent teeth with mature apex. Key words: Regeneration, i-PRF, Mature teeth, Apical healing, Root canal treatment, Pulp revascularization.

Outcomes of an alternative cervical sealing material in traumatized immature teeth subjected to pulp revascularization: a case series

Pulp revascularization is a viable and effective treatment for immature necrotic teeth. The purpose of this case series was to report the outcomes of pulp revascularization using an alternative cervical sealing material (composed by calcium hydroxide, 2% chlorhexidine gel, and zinc oxide), which showed an acceptable clinical and radiographic performance in further indications, such as root canal filling and root resorptions. Case report: We selected seven traumatized immature permanent maxillary central incisors with crown fracture, extrusive luxation, and pulp necrosis. For pulp revascularization, we followed four main steps: passive decontamination, three-week interappointment dressing, scaffold, and cervical sealing. The cervical sealing was carried out with the association of calcium hydroxide, 2% chlorhexidine gel, and zinc oxide in a proportion of 2:1:2. The follow-up period was 24 months. We classified pulp revascularization outcomes as complete healing, incomplete healing, or failure. All cases showed complete healing.

Effect of tetracyclines on pulpal and periodontal healing after tooth replantation: a systematic review of human and animal studies

BackgroundPulpal and periodontal healing are two main concerns of delayed replantation of avulsed teeth. The objective of this review was to evaluate the effectiveness of topical and systemic application of tetracyclines on pulpal and periodontal healing after tooth replantation.MethodsA comprehensive electronic search was conducted in six databases. This systematic review was carried out according to Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.ResultsAfter exclusion of 246 irrelevant papers, 14 animal studies and one human study were included in this review. The human study showed that avulsed permanent teeth treated with doxycycline did not show a better clinical outcome for pulp and periodontal healing compared with treatment with normal saline. As for animal studies, significant more pulpal healing was observed in immature teeth treated with topical doxycycline in two researches, while another one study showed that there is no difference between teeth treated with normal saline and teeth treated with doxycycline. Systemic doxycycline exerted no significant effect on pulpal revascularization illustrated by one research. Only one out of four articles illustrated the positive effect of systemic tetracyclines on periodontal healing. One paper reported that intracanal application of demeclocycline promoted favorable periodontal healing. Two articles showed topical doxycycline contributed to favorable periodontal healing, while five studies showed no significant effect of topical tetracyclines on periodontal healing.ConclusionsAs a result of data heterogeneity and limitations of the studies, the effect of topical or systemic application of tetracyclines on pulpal and periodontal healing is inconclusive. More studies are required to get more clinically significant conclusions.

Transplante Dentário Autógeno – Relato de caso clínico

O transplante dentário autógeno dentário é caracterizado pela translocação de um elemento para outro espaço alveolar. É um procedimento considerado como um tratamento reabilitador, com bom prognóstico principalmente para pacientes jovens. Apresentando como grande vantagem o menor custo se comparada com a reabilitação com implantes e próteses fixas, além de grande aceitação pelo paciente por ser um dente próprio, sem envolver materiais “nonself”. O objetivo deste trabalho é expor um relato de caso sobre transplante dentário relacionado com dentes supranumerários em região anterior de maxila. Em que foi realizada a partir de conceitos dos princípios éticos e após assinatura do Termo de Consentimento Livre e Esclarecido (TCLE) pelo responsável. Paciente melanoderma, 14 anos, apresentando elemento supranumerário na região do elemento 11. Após exames imaginológicos pôde-se notar a presença do elemento 11 impactado por palatino. Foi realizada a remoção do supranumerário e do elemento 11, sendo este transplantado para o seu alveolo ideal, sendo mantido em posição com auxílio de contenção semirrígida. No 35º dia pós operatório, o paciente apresentou uma excelente recuperação e cicatrização dos tecidos periodontais. Foi retirada a esplintagem verificando-se boa estabilidade da unidade, sem mobilidade, ausência de sinais flogísticos ou alterações pulpares ao teste de vitalidade. Ao exame radiográfico percebeu-se boa adaptação da raiz, sem sinais de reabsorção. Entretanto, a literatura afirma que este acompanhamento deve ser feito por até 1 ano, objetivando analisar revascularização pulpar e necessidade posterior de endodontia. Até o presente momento, após 2 meses de follow up, o paciente não apresenta sinais de necrose pulpar e está em programação de iniciar o tratamento ortodôntico. Assim, pode-se afirmar que este é um tratamento reabilitador válido e acessível, e quando bem indicado traz bons resultados.

Mechanisms Involved in Apice Closure of Pulpless Teeth – Literature Review

Background: Unfinished root formation has always offered challenges in endodontics due to technical difficulties and weakened teeth resistance during the lifetime of an individual. Pulp revascularization therapy appeared as a solution for apical closure and root maturation. The existence of oral stem cells involved in the process associated with traditional resident cells requires adequate blood supply given by induced controlled injury deliberately accomplished into the periapical zone. Objective: The aim of this work was to research, through literature review, the main mechanisms involved in the process of apical closure through the technique of pulp revascularization. Conclusion: Apice closure in pulpless teeth seems to happen as a result of professional intervention and biological activity. The success rate depends on the role of traditional local immune cells and stem cells associated with adequate blood supply to finish root formation.

The effects of reducing the root length by apicoectomy on dental pulp revascularization following tooth replantation in mice.

Root length is a critical factor for dental pulp regeneration following tooth replantation. The aim of this study was to analyze the effects of reducing the root length by apicoectomy on the pulp healing process using a model for tooth replantation. After extraction of the upper first molars (M1) of 3-week-old mice, the roots from the experimental group (EG) were shortened to half to two-thirds of their length before replantation, whereas in the control group (CG) the extracted teeth were immediately repositioned into their alveolar sockets. To determine the effects of root resection on the survival of inherent pulp cells, this study included tooth transplantation with root resection using wild-type (WT) and green fluorescent protein (GFP) transgenic mice. The M1 of GFP transgenic mice were transplanted into the alveolar socket of the M1 of WT mice. The roots of the right M1 were shortened (EG), whereas the left M1 remained untreated (CG). Apoptotic cells in the EG significantly decreased in number compared with the CG at day 3. Cell proliferative activity in the EG was significantly higher than that in the CG in the root pulp during days 3-5, and nestin-positive odontoblast-like cells began to arrange themselves along the pulp-dentin border in the cusp area at day 5 in the EG but not in the CG. At week 2, tertiary dentin had formed throughout the pulp in the EG, whereas the combined tissue of dentin and bone occupied the pulp space in 60% of the CG. Root resection also positively affected the survival of inherent pulp cells to differentiate into odontoblast-like cells as demonstrated by transplantation using GFP transgenic mice. Reducing the root length accelerated pulp regeneration following tooth replantation due to the better environment for revascularization.

PULP REVASCULARISATION OF NECROTIC IMMATURE PERMANENT TEETH: A REVIEW

As the importance attributed to conservative endodontic treatment increases manifold, pulp revascularization represents a recent and promising therapy for immature teeth, highly recommended as an alternative to apexification in cases of endodontic treatment of irreversible pulpitis and pulp necrosis, whether or not associated with periapical lesion. This review is an attempt towards the recommendation of revascularization as an alternative to apexification. KEYWORDS: Revascularization, Apexification, Regenerative endodontics, SCAP, Triple antibiotic paste

Angiogenic hydrogels for dental pulp revascularization

Angiogenesis is critical for tissue healing and regeneration. Promoting angiogenesis in materials implanted within dental pulp after pulpectomy is a major clinical challenge in endodontics. We demonstrate the ability of acellular self-assembling peptide hydrogels to create extracellular matrix mimetic architectures that guide in vivo development of neovasculature and tissue deposition. The hydrogels possess facile injectability, as well as sequence-level functionalizability. We explore the therapeutic utility of an angiogenic hydrogel to regenerate vascularized pulp-like soft tissue in a large animal (canine) orthotopic model. The regenerated soft tissue recapitulates key features of native pulp, such as blood vessels, neural filaments, and an odontoblast-like layer next to dentinal tubules. Our study establishes angiogenic peptide hydrogels as potent scaffolds for promoting soft tissue regeneration in vivo. Statement of SignificanceA major challenge to endodontic tissue engineering is the lack of in situ angiogenesis within intracanal implants, especially after complete removal of the dental pulp. The lack of a robust vasculature in implants limit integration of matrices with the host tissue and regeneration of soft tissue. We demonstrate the development of an acellular material that promotes tissue revascularization in vivo without added growth factors, in a preclinical canine model of pulp-like soft-tissue regeneration. Such acellular biomaterials would facilitate pulp revascularization approaches in large animal models, and translation into human clinical trials.

The role of angiogenesis and pulpal healing in tooth replantation and allograft transplantation

Tooth transplantation is one of the treatment options for extracted teeth that can be considered before dental implantation. Although the success rate of tooth transplantation is lower than that of implantation, tooth replantation and transplantation have the great advantage of using natural teeth. Tooth replantation might be considered a promising option in some cases. In present study, the expression patterns of revascularization and pulpal healing, which are the most important for the pulp viability, were analyzed after tooth replantation and allograft in mice. The inflammatory response and root dentin resorption were observed and not different between replantation and allograft in initiation of healing process. However, bonelike tissue formation, pulp revascularization and pulp healing were faster in replantation. The difference of healing patterns between tooth replantation and allograft found in present study will be helpful to select the treatment option and to understand healing mechanism.

Different Approaches to the Regeneration of Dental Tissues in Regenerative Endodontics

(1) Background: The regenerative procedure has established a new approach to root canal therapy, to preserve the vital pulp of the tooth. This present review aimed to describe and sum up the different approaches to regenerative endodontic treatment conducted in the last 10 years; (2) Methods: A literature search was performed in the PubMed and Cochrane Library electronic databases, supplemented by a manual search. The search strategy included the following terms: “regenerative endodontic protocol”, “regenerative endodontic treatment”, and “regenerative endodontics” combined with “pulp revascularization”. Only studies on humans, published in the last 10 years and written in English were included; (3) Results: Three hundred and eighty-six potentially significant articles were identified. After exclusion of duplicates, and meticulous analysis, 36 case reports were selected; (4) Conclusions: The pulp revascularization procedure may bring a favorable outcome, however, the prognosis of regenerative endodontics (RET) is unpredictable. Permanent immature teeth showed greater potential for positive outcomes after the regenerative procedure. Further controlled clinical studies are required to fully understand the process of the dentin–pulp complex regeneration, and the predictability of the procedure.

PLATELET RICH FIBRIN SCAFFOLD COMBINED WITH INDUCED BLOOD CLOT IN PULP REVASCULARIZATION OF NECROTIC IMMATURE PERMANENT TEETH WITH CHRONIC PERIAPICAL LESIONS: A CASE SERIES

ABSTRACT Background: Traumatized non-vital permanent teeth with incomplete root formation and divergent apices present particular challenges to clinicians during management with traditional approaches. Objectives: This report described the outcomes of pulp revascularization of three traumatized immature necrotic permanent teeth using platelet-rich fibrin scaffold combined with induced blood clot. Materials and Methods: Three patients (two boys aged 8 and 11 years and one girl aged 13 years) were presented with immature maxillary incisors with necrotic pulps. Access cavities were prepared and the root canals were gently irrigated with 1.5% sodium hypochlorite (20 mL/ 5 min). Calcium hydroxide paste was applied three mm short of the root apex and the canals were temporized with intermediate restorative material. At the following appointment after two weeks, the teeth were treated by revascularization protocol using Platelet rich fibrin scaffold combined with induced blood clot and the three cases were clinically and radiographically followed up to eighteen months. Results: The patients were clinically asymptomatic at all follow-up periods. Cone Beam Computed Tomography (CBCT) images revealed evidence of root maturation and healing of the periapical lesions. Calcific intra-canal deposits were noted at the middle and apical thirds of the root canals. Conclusions: Pulp revascularization procedure using Platelet rich fibrin scaffold showed evidence of root elongation, increased dentin thickness and resolution of the periapical lesions.

Successful immediate autotransplantation of immature maxillary third molar to rehabilitate grossly mutilated second molar: A 4-year follow-up case report

Autotransplantation is a viable option for immediate rehabilitation of missing teeth in young patients. It aims to preserve pulp vitality and proprioception, aiding complete root formation and osseous development, resulting in esthetic outcomes. A 20-year-old healthy female patient presented with pain in relation to a grossly mutilated nonrestorable right upper second molar tooth. Due to the young age of the patient, the proposed treatment was autotransplantation of upper third molar with incompletely formed roots to rehabilitate the second molar. Following precise diagnosis and application of strictly standardized treatment protocols, the strategically chosen donor tooth was atraumatically extracted and transplanted into the recipient site causing minimal damage to the periodontal ligament cells (PDLs). Clinical and radiographic findings over the 4-year follow-up period demonstrated normal gingival healing along with gradual bone regeneration. There was continued root formation and pulp revascularization with subsequent partial pulp canal obliteration. Higher survival rates of transplanted teeth are significantly associated with strict case selection criteria and protection of PDL. An analysis of pertinent prognostic factors with a long-term follow-up is required to predict and improve the outcome of tooth transplantation.