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Regenerative Endodontic Treatment (Revascularization) for Necrotic

Immature Permanent Molars: A Review and Report of Two Cases with a New
Biomaterial

Article  in  Journal of endodontics · April 2011

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Case Report/Clinical Techniques
Regenerative Endodontic Treatment (Revascularization)
for Necrotic Immature Permanent Molars: A Review
and Report of Two Cases with a New Biomaterial
Ali Nosrat, MS, DDS,* Amir Seifi, DDS, PhD,† and Saeed Asgary, MS, DDS‡
Abstract
Introduction: Revascularization is a valuable treatment
in immature necrotic teeth that allows the continuation
of root development. In this article we describe success-
ful revascularization treatment of 2 necrotic immature
first mandibular molars. Methods: The clinical and
radiographic examinations showed extensive coronal
caries, immature roots, and periapical radiolucencies
in mandibular first molars of a 9-year-old boy and an
8-year-old girl. The exam findings suggested revascular-
ization treatment in both cases, which was started with
irrigation of the canals by using NaOCl 5.25% for 20
minutes, followed by 3 weeks of triple antibiotic (metro-
nidazole, ciprofloxacin, and minocycline) paste dressing.
Next, the antibiotic paste was removed, bleeding was
induced in the canals, and calcium enriched mixture
(CEM) cement was placed over blood clots. Results:
In radiographic and clinical follow-ups both cases
were asymptomatic and functional, periapical radiolu-
cencies were healed, and roots continued to develop.
Conclusions: Revascularization is a realistic treatment
in immature necrotic molars. In addition, placing CEM
cement as a new endodontic biomaterial over the blood
clot formed inside the canals provided good seal and
favorable outcomes. (J Endod 2011;37:562–567)
Key Words
Apexification, calcium enriched mixture, CEM cement,
open apex, regenerative treatment, revascularization,
triple antibiotic paste
From the *Department of Endodontics, School of Dentistry,
Rafsanjan University of Medical Sciences, Rafsanjan, Kerman,
Iran; †Department of Oral Biology, School of Dentistry, Univer-
sity of Washington, Seattle, Washington; and ‡Iranian Centre
for Endodontic Research, Dental Research Centre, School of
Dentistry, Shahid Beheshti University of Medical Sciences, Teh-
ran, Iran.
Address requests for reprints to Dr Ali Nosrat, Department
of Endodontics, School of Dentistry, Rafsanjan University of
Medical Sciences, Aliebneabitaleb Blvd, Rafsanjan, Kerman,
Iran. E-mail address: ansrt2@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2011 American Association of Endodontists.
doi:10.1016/j.joen.2011.01.011
562 Nosrat et al.
T reatment of necrotic immature teeth has always been a challenge in endodontics. It is
difficult to get an appropriate apical seal in teeth with open apices by using the
conventional endodontic treatment methods. The discontinued development of dentinal
walls after the pulp necrosis can also lead to a weak root structure with thin dentinal
walls, which makes the tooth susceptible to future fractures (1). Traditionally,
multiple-visit apexification with calcium hydroxide was the treatment of choice in
necrotic immature teeth, which would induce formation of an apical hard tissue barrier
(2). Although this approach was predictable and successful (3), long-term use of
calcium hydroxide has several disadvantages such as multiple treatment appointments,
probable recontamination of the root canal system during treatment period, and
increased brittleness of root dentin, which increases the risk of future cervical root frac-
tures (3, 4).
An alternative technique for apexification with calcium hydroxide is artificial apical
barrier technique, which is done by placing barrier material in apical portion of the
canal. The material of choice for this technique is mineral trioxide aggregate (MTA)
(5), which has been shown to have high success rates (6–8) and reduce the
number of required clinical sessions. Both of the mentioned methods (ie,
apexification and artificial apical barrier techniques) share the same disadvantage of
not allowing the continuation of root development, which leads to a fragile root
structure.
Revascularization is a regenerative treatment and a biologically based alternative
approach to treat necrotic immature teeth that, unlike apexification and artificial apical
barrier techniques, allows continuation of root development (9, 10). Several types of
stem cells including dental pulp stem cells (DPSCs), which are more populated in
central cell rich zone of the pulp, bone marrow stem cells (BMSCs), stem cells from
human exfoliated deciduous teeth (SHED), and stem cells from apical papilla
(SCAPs) have exhibited different levels of ability to generate osteoid and odontoid
structures (11). SCAPs are the source of primary odontoblasts that are responsible
for continuation of root development (12, 13) and, as a result of proximity to the
periodontal blood supply, can survive pulp necrosis even in the presence of
periradicular infection (12, 14). In the optimal situation (ie, elimination
of microorganisms and their by-products and necrotic tissues and in the presence of
a protein scaffold and a tight coronal seal) these stem cells can populate in the root
canal space of necrotic immature tooth (15, 16).
The proposed regenerative treatment generally starts with chemical disinfection of
the canals by using passive NaOCl (17, 18), NaOCl-chlorhexidine (15, 19, 20), or
NaOCl–hydrogen peroxide 3% (21, 22) irrigation without any instrumentation.
Different concentrations of NaOCl including 6% (20, 23), 5.25% (15, 17, 19), 2.5%
(21, 24, 25), and 1.25% (18) and different concentrations of chlorhexidine including
2% (20, 23) and 0.12% (19) have successfully been used for this purpose. The proce-
dure continues by a triple antibiotic dressing including ciprofloxacin + metronidazole+
minocycline, as suggested by Hoshino et al (26). The required time of dressing varies
between few days to few months in different studies (15, 17–19). In the absence of
clinical signs and symptoms of periradicular diseases (ie, sensitivity to percussion or
palpation, presence of swelling, redness, or sinus tract, and suppuration or
exudation from canals), the treatment continues with removing the paste and
inducing bleeding inside the canals by irritating the apical tissues with a sterile file
JOE — Volume 37, Number 4, April 2011

(18, 19), endodontic explorer (15), paper points (27), or needle (21).
After formation of a blood clot, the orifice of the canal is sealed with
MTA, a biocompatible sealing material, which allows the regeneration
of new tissue adjacent to it (15, 19). Finally, the crown is
permanently restored. There is one clinical study that reports
successful use of glass ionomer instead of MTA (21). Several case
reports, case series, and clinical studies have been published that
demonstrate successful results for this technique and material in treat-
ing immature necrotic teeth (15, 17–20). However, there are 2 other
different methods of disinfection reported in which calcium
hydroxide with (22) or without bleeding induction (24, 25) or
formocresol (21) has been successfully used instead of triple antibiotic
paste. A retrospective evaluation of radiographic outcomes revealed that
revascularization with triple antibiotic dressing produced significantly
greater increases in root wall thickness than either the calcium
hydroxide or formocresol, and disinfection by formocresol caused
the smallest improvement in length and thickness of the roots (28).
Moreover, a case series study on revascularization treatment by using
calcium hydroxide as intracanal disinfectant revealed that a 10- to
29-month (mean, 16) period of follow-up is necessary to judge radio-
graphic evidence of root development (25).
Revascularization treatment has some ambiguities and drawbacks
that need to be resolved. The nature of the tissue formed in the canal
space and its cellular composition are yet to be identified (16); 2 recent
animal studies demonstrated that the vital tissue formed in canal space
was a connective tissue similar to periodontal ligament (29, 30), and
the dentinal walls were thickened by the opposition of newly formed
cementum-like tissue (29). Possible development of resistant bacterial
strains (31) and crown discoloration as a result of presence of mino-
cycline in the triple antibiotic paste (27) are 2 other drawbacks of this
technique. Presence of MTA in cervical portion of the canal is also re-
ported to cause crown discoloration (19, 20, 32). Shin et al (23) pre-
sented a single-visit technique of revascularization without using triple
antibiotic dressing, which might be a possible way to avoid both discol-
oration and development of resistant bacterial strains. They used only
NaOCl 6%, followed by chlorhexidine gluconate 2% irrigation in
coronal portion of the root canal of a necrotic mandibular premolar,
and after 5 minutes, they placed MTA without inducing bleeding. The
outcomes showed a successful revascularization and complete root
development. In addition, in an animal study, da Silva et al (30) intro-
duced a new technique for root canal disinfection of immature teeth by
using 2.5% NaOCl irrigation and apical negative pressure without using
Case Report/Clinical Techniques
triple antibiotic paste. Considering the histologic evidence of successful
revascularization, they have concluded that this new technique is
a promising disinfection protocol in necrotic immature teeth, and the
use of triple antibiotic paste might not be necessary. Thibodeau and
Trope (18) reported successful use of cefaclor instead of minocycline
in triple antibiotic paste, which might be an effective approach to
prevent the discoloration caused by minocycline. A recent report intro-
duced a successful technique to prevent discoloration in the presence of
minocycline. They sealed the dentinal walls of the access cavities of 2
bilateral necrotic immature premolars by using dentin bonding and
composite resin before placement of the triple antibiotic dressing (20).
Calcium enriched mixture (CEM) cement is a tooth-colored water-
based cement with same clinical applications as MTA, but it has different
chemical composition (33, 34). Sealing ability, cytotoxicity, and
biocompatibility of CEM cement are comparable to MTA (35–38),
and unlike MTA, the surface characteristics of set CEM cement are
similar to human dentin, which has the ability to promote
hydroxyapatite formation even in normal saline solution and might
promote the process of differentiation in stem cells and induce hard
tissue formation (34, 39).
This article describes 2 cases of successful revascularization in
necrotic immature molars by using CEM cement as a new endodontic
biomaterial with a modified approach in blood clot formation stage.
Case Reports
Case 1
A healthy 9-year-old boy was referred to our clinic with swelling
and lingering pain on chewing on the right side of his lower jaw. Clinical
examination revealed a broken tooth-colored restoration and extensive
caries on the lower right first molar, with notable localized swelling in
the buccal mucosa and also sensitivity to percussion and palpation. Cold
test with Endo-Frost cold spray (Roeko; Coltene Whaledent, Langenau,
Germany) elicited no response, whereas the left mandibular first molar
responded to cold without lingering. The periodontal status was normal
(ie, probing depth <3 mm around the tooth), and tooth showed no
mobility. The tooth had immature roots in the radiographs, with radio-
lucent periapical lesions adjacent to the distal and mesial roots
(Fig. 1A). Considering our clinical tests, the concluding diagnosis
was pulpal necrosis with symptomatic apical periodontitis, and our first
and optimal treatment option considering the immaturity of the tooth
was revascularization.

Figure 1. (A) Preoperative periapical radiograph of first right mandibular molar with localized swelling in case 1. Patient’s chief complaint was lingering pain and
pain on chewing. Note extensive coronal caries, remnants of previous damaged tooth-colored coronal restoration, immature roots, and periapical radiolucency
adjacent to distal and mesial roots. (B) Postoperative radiograph after root canal disinfection, placement of CEM cement over blood clot in both roots, placement of
glass ionomer base, and coronal restoration with amalgam. Bleeding induced in mesial canals was not sufficient, and blood level in orifices could not be seen. (C)
Follow-up radiograph at 18 months after operation. Tooth was functional without signs/symptoms. Periapical radiolucencies were healed. Distal root was fully
developed, but mesial root showed only thickening of the root walls. Poor radiographic outcomes in mesial root could be attributed to insufficient bleeding.

JOE — Volume 37, Number 4, April 2011 Revascularization for Necrotic Immature Permanent Molars 563
Case Report/Clinical Techniques
After complete explanation of the treatment procedure, risks, and
benefits, an informed consent was obtained from the patient’s legal
guardians. After rubber dam isolation without local anesthesia, the re-
maining coronal restoration and caries were removed, and an access
cavity was prepared by using a diamond-coated fissure bur (Diatech,
Heerbrugg, Switzerland) and a high-speed handpiece with copious
water spray. On entering the pulp chamber, pus and necrotic tissues
in mesial and distal canals were observed. The canals were passively
irrigated with 20 mL of 5.25% NaOCl for 20 minutes. To facilitate proce-
dure in mesial canals, the coronal part of the canals was widened
passively with Gates Glidden drill size #3 (Dentsply Maillefer, Tulsa,
OK). The patient did not have any pain during the procedure, which
confirmed the diagnosis of pulp necrosis. Canals were gently dried
with paper points (Ariadent, Tehran, Iran), and a creamy paste of equal
proportions of metronidazole (ParsDaru, Tehran, Iran), ciprofloxacin
(AminDaru, Tehran, Iran), and minocycline (Razak, Tehran, Iran) was
mixed with normal saline and placed inside all of the canals with a K-file
size #25 (Dentsply Maillefer) to 3 mm shorter than radiographically
estimated length, and the tooth was restored temporarily with Cavite
(Asia Chemi Teb Co, Tehran, Iran). At the 3-week follow-up the patient
was asymptomatic, the tooth was not sensitive to percussion and palpa-
tion, and the localized swelling was resolved. The tooth was anesthetized
with 3% plain mepivacaine (Septodont, Cedex, France) without vaso-
constrictor to facilitate bleeding, as suggested by Petrino et al (19). After
rubber dam isolation and removal of the temporary restoration, the
triple antibiotic paste was removed from the canals by 10 mL irrigation
of 5.25% NaOCl per canal, and canals were dried with paper points.
Apical tissues were irritated by using #40 K-file in distal canal and
#20 K-file in mesial canals. Bleeding started immediately in distal canal,
but in the mesial canals, blood could be seen only on the apical part of
the file, and we did not see any blood level in the orifices. After 10
minutes, CEM cement (BioniqueDent, Tehran, Iran) powder and liquid
were mixed according to the manufacturer’s instructions and placed
over the orifices by using an amalgam carrier and gently adapted to
dentinal walls by using a moistened cotton pellet. CEM placement was
much farther apically in the distal canal than desired. Because CEM
is a water-based cement, the access cavity was filled with normal saline,
immediately a moistened cotton pellet was placed over the CEM cement,
and the tooth was restored temporarily with Cavite. One day later, the
temporary restoration was removed, and CEM setting was verified. An
approximately 2-mm-thick layer of glass ionomer (Fuji; Fuji Corpora-
tion, Osaka, Japan) base was placed over the set CEM cement, and
the tooth was restored permanently with amalgam (SDI gs80; SDI
Limited, Bayswater, Victoria, Australia) (Fig. 1B).
The patient was recalled at 3, 6, 12, and 18 months after treatment.
In clinical examinations, the tooth was functional, without sensitivity to
percussion and palpation or presence of swelling, with normal peri-
odontal condition. Also, the tooth was not responsive to cold tests. In
radiographic examinations, radiolucent lesions on mesial and distal
roots healed, the distal root was fully developed, but the mesial root
showed only thickening of the walls (Fig. 1C).
Case 2
An 8-year-old girl was referred to our clinic with local extraoral
and intraoral swelling on the right side of the mandible in the area of
first molar. The patient’s medical history was noncontributory. Clinical
examination showed extensive caries in the mandibular right first
molar, sensitivity to palpation but not to percussion, and visible swelling
and redness in buccal mucosa with a draining sinus tract. The swelling
was visible extraorally along the lower border of the mandible, which
was tender to palpation. A cold test with Endo-Frost cold spray elicited
no response, whereas the left first mandibular molar responded nor-
mally without lingering pain. Periodontal exams confirmed normal
probing depth (ie, <3 mm) all around the tooth and normal physiologic
mobility. Radiographic examination showed an immature tooth, with
a possible apical resorption of the mesial root, and radiolucent lesions
at the furcation and periapical areas of mesial and distal roots. To locate
the source of the sinus tract, we traced it by using a gutta-percha point
(Fig. 2A). Considering our diagnostic tests, we found the first right
mandibular molar to have pulpal necrosis with chronic apical abscess.
After informed consent was obtained from the patient’s legal
guardians, the tooth was isolated with rubber dam without anesthesia,
and the access cavity was prepared. On entering the pulp chamber, no
purulent drainage was observed, and the patient did not feel any pain
during the procedure. After irrigation of canals by using the same tech-
nique described in case 1, canals were dried, triple antibiotic paste was
placed inside the canals, and the tooth was temporized with Cavite for 3
weeks. At the following appointment, the patient was asymptomatic, the
tooth was not sensitive to palpation and percussion, and the sinus tract
and swelling were resolved. Under local anesthesia with 3% plain me-
pivacaine without vasoconstrictor and rubber dam isolation, the tempo-
rary restoration and triple antibiotic paste were removed, and the apical
tissues in all canals were irritated by using the same technique as

Figure 2. (A) Preoperative periapical radiograph of first right mandibular molar with extensive caries and draining sinus tract in case 2. Patient’s chief complaint
was localized intraoral and extraoral swellings. Note immaturity of roots, apical resorption of mesial root, and periapical and furcal radiolucent lesions. (B) Post-
operative radiograph after root canal disinfection, bleeding induction, placement of CEM over blood clot, placement of glass ionomer base, and coronal restoration
with stainless steel crown. Bleeding induced in mesial canals was not sufficient; therefore, the clinician delivered fresh blood from distal canal to mesial canals. (C)
Follow-up radiograph at 15 months after operation. Sinus tract resolved, and tooth was functional and asymptomatic. Note osseous healing in periapical and furcal
areas, thickening of root walls in the area of internal root resorption, and full mesial and distal root development.

564 Nosrat et al. JOE — Volume 37, Number 4, April 2011


described in case 1. The bleeding produced in distal canal filled the
canal to the orifice level; however, in mesial canals, we encountered
the same problem as in case 1; bleeding was not visible in the orifices.
We then decided to use blood from the distal canal. Therefore, the
apical tissue in distal canal was again irritated by using K-file size #40
to produce more bleeding, and the excess blood was delivered to me-
siobuccal and mesiolingual canals by using a sterile medical injection
27-gauge syringe (Supa, Tehran, Iran). Then the delivered blood was
gently agitated with sterile K-file size #15 to facilitate the flow of the
blood to the apical portion. After 10 minutes, after the formation of
blood clot in all canals, the CEM cement powder and liquid were mixed
according to manufacturer’s instructions and placed over blood clot,
and the tooth was temporarily restored by Cavite. One day later, after
removing temporary restoration, CEM setting was checked, and a 2-
mm-thick glass ionomer base was placed over set cement, the tooth
was temporized, and the patient was referred to a pedodontist for
a coronal restoration with stainless steel crown (Fig. 2B).
Three, six, twelve, and fifteen months after the treatment, the
patient was recalled to evaluate the outcome. Recall exams showed
the tooth to be asymptomatic and functional. There were no clinical
signs of infection or inflammation such as sinus tract or swelling or
sensitivity to percussion and palpation. The response to cold tests
was negative in all recalls. The periodontal exams revealed normal phys-
iologic mobility and no pocket depth greater than 3 mm. Radiographs
showed periapical and furcation bone healing and full mesial and distal
root development. Also, the root wall thickness in the area of apical
resorption in mesial root increased (Fig. 2C).
Discussion
The main advantages of revascularization technique over the tradi-
tional apexification or artificial barrier technique in endodontic treat-
ment of immature necrotic teeth include continuation of root
development and strengthening the root structure (28). Anatomical
complexities in multirooted teeth make using the traditional techniques
more difficult, and in some cases it is impractical. In these 2 cases we
decided to use revascularization treatment instead of apexification with
calcium hydroxide or artificial barrier technique because of the poten-
tial to gain the benefits of root development.
Elimination of microorganisms and necrotic tissues from the root
canal system is the key factor in a successful revascularization. Studies
have revealed that chlorhexidine irrigation might have cytotoxic effects
on human cells (40) and interfere with the attachment of DPSCs to the
root canal walls (41). Thus, we only used NaOCl 5.25% for irrigation
of the canals instead of NaOCl + chlorhexidine irrigation, which was
described by Ding et al (17). Studies have reported different methods
for disinfecting the necrotic immature teeth in revascularization treatment
including the use of triple antibiotic paste (15, 19), calcium hydroxide
(24, 25), and formocresol (21). Whereas Hoshino et al (26) and Sato
et al (42) in 2 separate in vitro studies used a mixture of metronidazole,
ciprofloxacin, and minocycline effectively against endodontic pathogens
that disinfected even the deep layers of dentin in infected teeth, an animal
study revealed that using triple antibiotic dressing in infected canals for 2
weeks resulted in bacteria-free culture in 70% of cases (43). Different
case reports and case series showed successful outcomes for revascular-
ization treatment by using this triple antibiotic dressing (15, 17, 19). We
also used the triple antibiotic dressing for 3 weeks in both cases and
obtained successful results. It seems that this antibacterial protocol
(ie, NaOCl 5.25% passive irrigation for 20 minutes followed by triple
antibiotic dressing) can disinfect necrotic immature root canals
effectively and leads to favorable clinical outcome even in complex
root canal anatomy of molar teeth.
JOE — Volume 37, Number 4, April 2011
Case Report/Clinical Techniques
Instrumentation is contraindicated in revascularization treat-
ments. Root dentinal walls are so thin that any instrumentation makes
them weaker and more susceptible to future fractures, and also forma-
tion of a smear layer could occlude the dentinal walls and tubules (9).
However, in these 2 cases we used Gates Glidden drills passively in the
coronal one third of the mesial canals to facilitate irrigation, placement
of triple antibiotic dressing into the mesial canals, and placement of
CEM cement on the blood clot.
Human dentin contains several angiogenic growth factors (44) that
can promote tissue regeneration in the root canal space. Therefore, it is
safe to assume that the blood clot in the disinfected empty root canal
space that contains platelet-derived growth factors along with growth
factors derived from dentinal walls plays the role of a protein-rich scaf-
fold that might be crucial for successful population and differentiation of
stem cells and, ultimately, root development (16). An animal study has
shown that root canals that had a blood clot formed inside them after
disinfection had better radiographic treatment outcomes regarding
the thickening of root canal walls and apical closure compared with
those that did not have a blood clot in the canal space. However, the
differences between histologic outcomes were not significant (45). A
clinical study revealed that failure to induce the blood clot after disinfec-
tion might be one of the reasons for treatment failures in revasculariza-
tion (17). In this report we encountered some difficulties in inducing
sufficient bleeding in mesial canals of both cases. In case 1 in which
we did not perform any compensating procedure, the outcome of revas-
cularization treatment in mesial canals was only thickening of the root
wall, and the root length did not increase. However, in case 2 in which
we delivered fresh blood from the distal canal to the mesial canals to
compensate for lack of bleeding, favorable results were obtained. There-
fore, poor radiographic outcomes in mesial root in case 1 could
partially be attributed to insufficient bleeding. One study suggested using
non-epinephrine local anesthetics to facilitate bleeding (19) as we did in
these cases, and sufficient bleeding in distal canals might be related to
the use of 3% plain mepivacaine. However, Ding et al (17) discussed that
decreased inflammatory reactions after disinfection procedure is the
main cause for lack of bleeding. It is possible that the smaller mesial
canal diameters with smaller apical openings that limit the use of larger
files for irritating apical tissues are other reasons for this problem in
both cases.
The importance of a bacteria-tight coronal seal for successful
revascularization is well-documented (15). A majority of reported
studies have used a double seal over the blood clot formed inside the
canal, MTA and a resin-bonded restoration (15, 18, 19). Sealing
ability and biocompatibility of MTA are shown in several studies
(46). An animal study on revascularization showed that a cemental
bridge has formed beneath MTA in most cases, which might be the result
of cementogenic and osteogenic properties of MTA (29). Completion of
these bridges over time might create a biological seal beneath MTA,
which is not indicated in that animal study because of the short period
of the study (3 months). Studies have documented that CEM is biocom-
patible material in vital pulp therapies (47–49), and its sealing ability,
biocompatibility, and cementogenic properties are identical to those of
MTA (36–38, 50–52); besides, CEM is an antibacterial biomaterial
(53). Therefore, as we showed in these cases, CEM is an appropriate
sealing biomaterial over blood clot in revascularization. In addition,
we used the glass ionomer base as a second sealing, followed by
a permanent coronal restoration in both cases. Successful outcomes
in these 2 cases might partly be the result of effective coronal seal.
Unlike MTA, CEM has the advantage of being tooth-colored (33)
and preventing the discoloration caused by the presence of MTA at
the orifice level, which is mentioned in some of the revascularization
reports (19, 20). Moreover, the surface characteristics of set CEM
Revascularization for Necrotic Immature Permanent Molars 565
Case Report/Clinical Techniques
cement as well as the distribution pattern of calcium, phosphorus, and
oxygen ions are similar to human tooth dentin (34), which can promote
differentiation process of stem cells.
Although there is no information about the histologic features of
tissue produced in root canal space of human teeth after revasculariza-
tion treatment, one animal study showed that 3 types of tissues were
generated after treatment including cementum-like tissue along the
dentinal walls responsible for root wall thickening, bone-like tissue,
and periodontal ligament–like tissue. Also, in one case, partially
survived pulp tissue and presence of odontoblast cells lining the
dentinal walls were evident (29). The study concludes that the tissue
formed in the canal space is not pulp and does not function like pulp
tissue, which means that revascularization is not pulp regeneration
but resembles wound repair process. We demonstrated in case 1 that
the nature of root development in mesial root differed from that in distal
root, which seemed to be more similar to normal root development in
distal root. If the vital tissues formed in these canals had been identical,
their function should have been the same, and the radiographic appear-
ance would have been similar. It seems that delivering blood from the
distal to the mesial root in case 2 provided the required cells and growth
factors, which caused similar root development pattern in both roots.
This hypothesis should be studied more.
In conclusion, the authors believe that revascularization of
necrotic immature teeth is a possible and more practical and valuable
treatment plan than traditional apexification with calcium hydroxide or
artificial apical barrier techniques. However, histologic studies on
human revascularized teeth and more clinical studies are recommen-
ded. In addition, using CEM cement as a new endodontic biomaterial
over blood clots instead of MTA is an applicable choice. Moreover, in
the cases with lack of bleeding after disinfection, preparing blood
from other disinfected canals or teeth was shown to be a practical
choice in our study. However, more studies with longer follow-up on
this proposed technique will be of value for finding reliable ways to
overcome the problem of lack of bleeding in these cases.
Acknowledgments
We acknowledge the contribution of Dr Anahita Bozorgma-
nesh (Assistant Professor, Department of Paedodontics, Dental
School, Rafsanjan University of Medical Sciences) in this study.
The authors deny any conflicts of interest related to this study.
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Case Report/Clinical Techniques
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