Regenerative Treatment of a Trauma-Induced Necrotic Immature Tooth

A Case Report
IUSD Department of Graduate Endodontics
C. B. THIESSEN * and M. M. VAIL
Abstract
Apexification techniques for immature, necrotic teeth offer high levels of success; however, an
alternative therapy may consist of regeneration in which the necrotic pulp tissue is removed and
replaced with vital pulp tissue to promote further physiologic development. This case report
describes the treatment of a trauma-induced necrotic, immature, permanent central incisor by a
regenerative approach instead of the conventional apexification technique. After the diagnosis of
necrosis with asymptomatic apical periodontitis, the tooth was accessed and purulent drainage noted.
The canal was disinfected with copious amounts of sodium hypochlorite. An interim treatment of
calcium hydroxide, followed by a mixture of a triple antibiotic paste was placed. After 8 weeks the
periapical tissue was mechanically stimulated to induce intracanal bleeding allowing a blood clot to
form up to the level of the cemento-enamel junction. Mineral trioxide aggregate was placed
coronally on top of the blood clot followed by a 6 mm seal of Cavit. After three months, both clinical
and radiographic evidence suggested a favorable biological response with this newly developed
treatment protocol. This case report confirmed that successful regeneration of previously necroticinfected canals is possible provided the canal environment can be effectively disinfected.

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Percussion Palpation Probing

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Figure 1: Initial Pulpal and Periapical Evaluation (0 = No Response, 1 = WNL)

A 15-year-old female was referred from Private Practice to the Graduate Endodontics Department at
the Indiana University School of Dentistry for evaluation and treatment of tooth #25. The medical
history was unremarkable. The patient reported falling on the ice several years prior and needed to
see a dentist to fix a chipped tooth. The clinical examination revealed no swelling,
lymphadenopathy, or other significant findings extraorally. Intraorally, no erythema, swelling, or
sinus tract was noted. The patient was asymptomatic and the initial pulpal/periapical evaluation
(Figure 1) revealed no cold or electric pulpal response with tooth #25. Periodontal probings were
within normal limits for all mandibular anterior teeth. Radiographic examination revealed a
periapical radiolucency associated with tooth #25 (Figure 2), adequate bone levels, intact PDL, and
apical root resorption with an immature/open apex. A diagnosis of necrosis with asymptomatic apical
periodontitis was made. Treatment options were discussed with the patient and legal guardian, and
informed consent was obtained. Under local anesthesia and rubber dam isolation, an access cavity
was made, purulent drainage achieved, and the necrotic pulp tissue confirmed. Working length
radiographs were taken with a 60 size file at 18.5 mm (Figure 3) and a 70 size file at 17 mm
(Figure 4), confirming a canal measurement of 17.5 mm. An irrigation needle was placed to within 1
mm of the apex, and the canal was flushed with 20 ml of 6% NaOCl for 10 minutes, followed by a 10
ml flush of sterile saline. Calcium hydroxide paste was placed within the canal with a Lentulo spiral,
and the access cavity was sealed with a sterile sponge, Cavit, and IRM (Figure 5).

2nd Appointment

10/22/08

The patient returned being asymptomatic after 8 weeks for continued regenerative treatment.
Calcium hydroxide (Figure 6) was removed by flushing with 6% NaOCl and sterile saline for 10
minutes. The canal was dried with paper points, and a triple antibiotic paste (Ciprofloxacin 200 mg,
Metronidazole 500 mg, and liquid Gentamicin 100 mg) was prepared and placed within the canal
with a Lentulo spiral. The access cavity was sealed with a sterile sponge, Cavit, and IRM.

The patient returned, asymptomatic, at the 3 month recall. Pulpal/periapical evaluation was
performed (Figure 9) and revealed tooth #25 responded vital to cold, electric, and direct cavity
stimulation. Radiographic examination showed evidence of healing of the periapical lesion along with
the in-growth of hard tissue (bone, dentin, cementum) formation within the canal (Figure 7). Cavit
was replaced with a composite resin restoration (Figure 8). The patient was then placed on a 3 month
recall.

Discussion
There are three main components of tissue engineering concepts in regenerative endodontics.3 The
first component is a reliable cell source, capable of differentiating. This case report focused on the
stem cells of the apical papilla. The second component is a physical scaffold to provide a
physiochemical and biological micro-environment for cell growth and differentiation, promoting cell
adhesion, and migration. The blood clot in this protocol served as this scaffold, and also provided a
source of growth factors to facilitate the regeneration and repair of tissues. The third component is
signaling molecules to stimulate cellular proliferation and directing cellular differentiation.
Figure 2: Pre-op Radiograph

Mechanical instrumentation, an important part of routine RCT, cannot be performed in immature teeth
because of the thin dentinal canal walls. Therefore, the disinfection relies solely on irrigation
solutions such as NaOCl and intracanal medicaments such as Ca(OH)2 and the triple antibiotic
mixture. Many tissues, including pulp tissue, are capable of regeneration and repair if given a
condition free of infection. The triple antibiotic mixture used has high efficacy in reducing bacteria in
infected canals. A study by Windley et al.4 showed that an intracanal delivery of a 20-mg/ml solution
of these three antibiotics by a Lentulo spiral resulted in a greater than 99% reduction in mean CFU
levels with roughly 75% of the root canal system having no cultivable microorganisms present. Even
though this tooth presented with a large periapical lesion, some vital tissue and Hertwigs epithelial
root sheath possibly remained. Therefore, when the canal was disinfected and the inflammatory
conditions reversed, these tissues were able to proliferate.

Figures 3 and 4: Working Length Radiographs

Regenerative endodontics is a biologically based procedure designed to replace damaged dentin and
root structures, as well as cells of the pulp-dentin complex, by comprising research in adult stem
cells, growth factors, organ-tissue culture, and tissue engineering materials.2 The present case report
describes the protocol to stimulate continued root development by regenerative endodontic treatment
in a case of trauma-induced necrosis of an immature permanent mandibular central incisor.

1st Appointment 8/27/08

The patient returned again being asymptomatic, reporting no pain postoperatively. The access was
opened and the canal was flushed again with 6% NaOCl and sterile saline for 10 minutes. The canal
appeared clean and dry, with no signs of inflammatory exudates. An endodontic 15 size file was
gently used to irritate the periapical tissue to create bleeding into the canal to the level of the CEJ.
Colla-Tape was then used to establish a blood clot. MTA was carefully placed over the blood clot,
followed by a 6 mm seal of Cavit as a temporary restoration.

4th Appointment 1/26/09

Background
Traumatic injury to an immature permanent tooth can lead to the loss of pulp vitality and impede root
development. Difficulty in treating these young teeth includes thin dentinal root walls, poor crownroot ratio, increased risk of fracture, and an open apex. Pulp vitality determines the treatment options
available. Apexogenesis is initiated in a vital pulp to encourage continued physiologic development
and root formation. Apexification is a method to induce a calcified barrier in a root with an open
apex or the continued apical development of an incompletely formed root in teeth with necrotic pulps.
These traditional treatments utilized long-term calcium hydroxide applications with more recent
techniques of mineral trioxide aggregate as an artificial barrier. Following these treatment
techniques, traditional root fillings (gutta percha) would be completed. However, the ideal treatment
to resolve or prevent apical periodontitis and obtain further root development along with increased
thickness of the dentinal walls in an immature tooth would be to stimulate the regeneration of a
functional pulp-dentin complex.1 Revascularization has been used to describe this process, however,
physiological tissue formation and regeneration is what actually occurs.

3rd Appointment 11/05/08

Figure 5: Calcium Hydroxide 1st Appointment

Figure 6: After 8 weeks of Calcium Hydroxide

Traditional treatment for immature teeth with a necrotic pulp does not promote further physiologic
development. This protocol initiates the induction of new vital tissue within the canal system. Vital
tissue can provide thickening and consequent strengthening of the root canal walls. This tissue,
however, has been reported to be more comparable to periodontal ligament than to pulpal tissue.5 The
radiographic presentation showed the in-growth of potential cementum, bone, or dentin-like material.
A previous case report by Banchs and Trope6 used a similar treatment protocol on an immature tooth
with open apex and a sinus tract. The tooth was flushed out with 5.25% NaOCl and filled with a
mixture of triple antibiotic paste. After 26 days the triple antibiotic mix was flushed with 5.25%
NaOCl and bleeding was established to a level of 3 mm below the CEJ, where MTA was placed over
the blood clot, and eventually restored with a resin restoration. The 2 year follow-up revealed closure
of the apex and thickening of the dentinal walls, along with responding positive to cold testing.

Figure 7: 3 Month Recall Radiograph

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Figure 8: 3 Month Recall Radiograph/ Resin Restoration

Percussion Palpation Probing

The outcome in this case report provided the initial measures of successful healing. This protocol
rendered a previously infected root canal, effectively bacteria free and allowed the in-growth of new
vital tissue into the canal system. The future development of regenerative endodontic procedures
should incorporate the knowledge of relative advantages and potential risks, and their application
towards patient treatment.

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Figure 9: Final Pulpal and Periapical Evaluation (1 = WNL)

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Windley W, et al. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439-43.
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