Page 167 - FINAL COMPENDIUM 2020-2021 27.2.2022

REGENERATIVE ENDODONTIC PROCEDURE IN IMMATURE PERMANENT TEETH: A CASE
SERIES

Wan Ahmed WA, Mohd Ariffin S, Che’ Azmi AS, Abdullah R
Introduction: Immature permanent teeth are at risk of developing pulpal necrosis
secondary to trauma, caries, and dental anomalies and presents a unique challenge in
endodontic management. Traditionally, these teeth are treated by apexification- either
by calcium hydroxide apexification or placement of mineral trioxide aggregate (MTA)
apical plug. Currently, regenerative endodontic procedure (REP) has evolved in the past
decade and is advocated as a viable treatment alternative for non-vital immature
permanent teeth. Regenerative endodontics is defined as a “biologically based
procedures designed to physiologically replace a damaged tooth structure, including
dentin and root structures, and the pulp-dentin complex”. The REP consists primarily of
the chemical debridement of the root canal system, with minimal to no mechanical
instrumentation. This is then followed by further root canal disinfection with an intracanal
medicament such as calcium hydroxide, triple antibiotic paste (mixture consisting of
ciprofloxacin, metronidazole, and minocycline in 1:1:1 ratio or double antibiotic paste.
Subsequent appointment involves induction of bleeding from the apical tissues into the
root canal system. Once a blood clot or scaffold is in place within the canal, a coronal
barrier is placed to prevent coronal leakage of microorganisms. The American Association
of Endodontics recommends using MTA or Biodentine® as a coronal plug followed by a
layer of glass ionomer cement and then a bonded reinforced resin composite restoration
as a coronal seal. The purpose of this case series is to report five REP cases that were
managed using different intracanal medicaments. Case study: This case series consists of
5 immature permanent teeth (4 anteriors and 1 premolar teeth) with apical periodontitis
in 5 patients, ranging from 8 – 13 years of age. 3 teeth were treated using irrigants, a triple
antibiotic paste, and a coronal seal of MTA or Biodentine®, glass ionomer cement and
resin composite. Another 2 teeth were treated using irrigants, placement of intracanal
medicaments comprising of a mixture of Ledermix and non-setting calcium hydroxide
Ca(OH)2, and a coronal seal of MTA, glass ionomer cement and resin composite. All teeth
showed evidence of favourable clinical outcomes. Teeth were asymptomatic, no sinus
tracts were evident and teeth were responsive to the electric pulp test (EPT).
Radiographically, there were resolution of periapical radiolucency, and evidence of
continuing thickness of dentinal walls, increased root length and apical closure. Although
current radiographic evidence were very modest, we are anticipating that with further
follow-up, the roots will continue to mature with increased thickness and length to obtain
apex closure. Thus, strengthening the predictability favourable radiographic outcome
after revascularisation. Based on this case series, regardless of the type of intracanal
medicaments used, outcomes are favourable as the successful outcome for REPs
procedure depends mainly on optimum canal disinfection, placement of a matrix in the
canal for tissue ingrowth (scaffold), and a bacterial-tight coronal seal of the access
opening.

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