Literature review
Pulp regeneration/revitalization in immature permanent teeth
Introduction: Treatment of affected immature teeth is a challenging procedure. Immature teeth have wide canals, thin dentin walls and open apices, in addition to being more prone to fracture and with a poor long-term prognosis. Revascularization of an immature tooth attempts to preserve the teeth as long as possible, but there are failures because it is difficult to achieve optimal disinfection of the root canal system.
Methods: An exhaustive search was carried out by consulting the electronic databases PubMed and Web of Science of the last 10 years, using keywords and eligibility criteria.
Results: The search process yielded 635 total articles. After applying filters, eliminating duplicates and selecting articles by title and abstract, only 27 were for the present study.
Conclusions: Pulp revitalization has high survival rates in the treatment of necrotic immature permanent teeth. Randomized clinical trials are needed to compare the effect of platelet-rich fibrin, platelet-rich plasma, and induced bleeding on the revitalization of a tooth with necrotic pulp. One of the main problems of pulp revitalization is coronal discoloration. Triple antibiotic paste is a very effective antimicrobial agent, but high concentrations could have a detrimental effect on stem cell survival.
KEY WORDS
Apical closure; Open apex; Immature teeth; Permanent teeth, Platelet-rich fibrin; MTA; Non-vital traumatized immature permanent; Pulp necrosis; Dental pulp regeneration.
During childhood and adolescence, traumatic dental injuries are common, causing damage to the tooth and its supporting structures, including root fractures, bone loss, and tooth loss1. The loss of permanent teeth at an early age may result in arrested growth of the alveolar bone, thereby impeding subsequent aesthetic and functional reconstruction2. Given the increasing desire to preserve natural teeth, a tooth with a poor prognosis presents a new challenge for dentists1.
The principal characteristic of young permanent teeth is incomplete root development. This results in an open apical foramen, thinner and more fragile root walls, an inadequate crown-root ratio, and an unformed root structure3. These particular characteristics of young permanent teeth mean that the required pulp treatments are different and should be as conservative as possible.
The management of affected immature teeth is among the most challenging procedures in endodontics. Owing to the fact that such immature teeth possess very wide canals, thin dentinal walls, and open apices, they present increased difficulty for the clinician during biomechanical preparation1,3. Furthermore, these are more prone to fracture and, therefore, have a poor long-term prognosis3,4.
Traditionally, immature teeth diagnosed with necrotic pulp are treated by apexification with calcium hydroxide (Ca(OH)2) or mineral trioxide aggregate (MTA)5,6. However, neither procedure allows for thickening of the root wall or continued root development7; consequently, these teeth become fragile and susceptible to fracture5.
Regenerative endodontic procedures represent a novel therapeutic approach that promotes continued root growth in necrotic immature teeth, potentially preventing root fracture5. The revascularisation of a traumatised immature tooth seeks to preserve the teeth for as long as possible2.
In pulpal revascularisation, the root canal is disinfected with antibiotics or antimicrobial agents8. Promotion of the blood clot is necessary following disinfection of the root canal system. In recent years, this promotion of the conventional clot (induced by over-instrumentation) has been replaced by the use of platelet-rich plasma or platelet-rich fibrin, which offer enhanced efficacy and a higher concentration of growth factors to promote dental bleeding7.
However, a significant concern in teeth undergoing regenerative endodontic treatment is achieving optimal disinfection of the root canal system6. Although revascularisation is an increasingly utilised treatment, clinical failure rates in the revitalisation of immature teeth may reach up to 40%8.
When pulp regeneration or revitalisation is performed, a significant proportion of cases fail. Therefore, it is necessary to identify the most effective techniques to undertake this treatment with minimal risk.
Jiménez-Pascual, Sandra
Graduated in Dentistry from the Complutense University of Madrid (UCM). Student of the Master’s Degree in Dental Sciences, UCM. Student of the Expert Course in Periodontal Clinic, UCM.
Gallardo-López, Nuria Esther
Medical specialist in Stomatology. Master’s degree in Paediatric Dentistry. Specialist in Comprehensive Dental Care for Children with Special Needs. Tenured lecturer in Dentistry (UCM).
Mourelle-Martínez, María Rosa
Medical specialist in Stomatology. Paediatrician. Medical Specialist in Occupational Medicine. Master’s degree in Paediatric Dentistry. Specialist in Comprehensive Dental Care for Children with Special Needs. Tenured lecturer in Dentistry (UCM).