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PULP REVASCULARIZATION OF
IMMATURE PERMANENT TOOTH
WITH NECROTIC PULP AND OPEN
APEX
DR. HOOR-E-JANNATH PRITY
OSD (ADDITIONAL), DGHS
DDS NON-RESIDENT, SYLHET MAG
OSMANI MEDICAL COLLEGE

INTRODUCTION
• Pulp revascularization is a
relatively new treatment
method for immature
necrotic permanent teeth.
• It induces continued root
formation and closure of
root apex.

CASE SELECTION
• Tooth with necrotic pulp and an
immature apex.
• Pulp space not needed for
post/core, final restoration.
• Compliant patient/ parent.
• Patients not allergic to
medications and antibiotics
necessary to complete
procedure.

Materials used for
irrigation
 Sodium hypochlorite
(1.5-3%)
 EDTA
 Normal saline

MATERIALS USED FOR DISINFECTION OF
CANAL
• Calcium hydroxide, or,
• Triple Antibiotic Paste

TRIPLE ANTIBIOTIC PASTE
• Made by mixing 1:1:1
Ciprofloxacin: Metronidazole:
Minocycline to a final
concentration of 1-5mg/ml.
• Alternatives to minocycline:
Clindamycin; Amoxicillin;
Cefaclor

FIRST APPOINTMENT
• Local anesthesia, Rubber
dam isolation and Access.
• Copious, gentle irrigation
with irrigating needle
positioned about 1mm from
root end, to minimize
cytotoxicity to stem cells in
the apical tissues.

FIRST APPOINTMENT (CONT.)
• Dry canals with paper points.
• Place calcium hydroxide or
low concentration of triple
antibiotic paste.
• Seal with 3-4mm of a
temporary restorative
material. Dismiss patient for
1-4 weeks.

SECOND APPOINTMENT (1-4 WEEKS AFTER FIRST VISIT)
• Anesthesia with 3%
mepivacaine without
vasoconstrictor, rubber
dam isolation.
• Copious, gentle irrigation
with 20ml of 17% EDTA.
• Dry with paper points.

SECOND APPOINTMENT (CONT.)
Create bleeding into
canal system by over-
instrumentation (pre-
curved K-file)
Stop bleeding at CEJ
Allow the blood to clot
Place MTA over the clot
Restore the tooth

FOLLOW-UP (6-, 12-, 24- MONTHS)
Clinical and Radiographic
examination
• No pain, soft tissue
swelling or sinus tract
(often observed between
first and second
appointments).
• Resolution of apical
radiolucency (often
observed 6-12 months
after treatment)

FOLLOW-UP
• Increased width of root walls
(this is generally observed
before apparent increase in
root length and often occurs
12-24 months after
treatment).
• Increased root length.
• Positive pulp vitality test
response.

MECHANISM OF PULP REVASCULARIZATION
• Evidences suggest that avulsed
immature permanent teeth can
be successfully revascularized
following reimplantation.
• In such cases, the necrotic but
infected pulp is believed to
have acted as a scaffold,
permitting the ingrowth of
tissue from the periapical area.

REQUIREMENTS FOR PULP
REVASCULARIZATION
• The stem cells arising from
dental papilla or apical
periodontium
• Remnants of Hertwig’s root
sheath
• An empty root canal space
free of bacteria
• Scaffold i.e., blood clot/ PRP

ADVANTAGES OF PULP REVASCULARIZATION
• Continued root development.
• Thickening of the dentinal walls.
• No risk of root fracture as in
case of apexification.
• Closure of root apex.
• Restoration of pulp vitality.

DISADVANTAGES OF PULP
REVASCULARIZATION
• Crown discoloration.
• Development of
resistant bacterial
strains.
• Allergic reaction to the
medication.

CAUSES OF UNFAVORABLE OUTCOMES
• Failure to induce any
bleeding; which might be
due to-
 Resolution of
inflammation
 Use of local anesthetics
with vasoconstrictors

CONCLUSION
• Teeth that have undergone pulp
revascularization have better
prognosis than teeth that
received apexification treatment.
• With thicker and longer roots,
risk of fracture of the tooth
decreases.
• This treatment modality should
be preferred to conventional
apexification procedure.

REFERENCES
• Nagy MM, Tawfik HE, Hashem AA, Abu-Seida AM. Regenerative potential of immature permanent teeth with necrotic pulps after
different regenerative protocols. J Endod. 2014 Feb;40(2):192-8.
• Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review
and report of two cases with a new biomaterial. J Endod 2011 Apr;37(4):562-7. Review.
• Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: a case series. J Endod 2010
Mar;36(3):536-41.
• Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids using a modified novel technique to
eliminate potential coronal discolouration: a case report. Int Endod J. 2009 Jan;42(1):84- 92.
• Rodríguez-Lozano FJ, Bueno C, Insausti CL, Meseguer L, Ramírez MC, Blanquer M, Marín N, Martínez S, Moraleda JM. Mesenchymal
stem cells derived from dental tissues. Int Endod J. 2011 Sep;44(9):800-6.

REFERENCES
• Vishwanat L, Duong R, Takimoto K, Phillips L, Espitia CO, Diogenes A, Ruparel SB, Kolodrubetz D, Ruparel NB. Effect of
Bacterial Biofilm on the Osteogenic Differentiation of Stem Cells of Apical Papilla. J Endod. 2017 Jun;43(6):916-922.
• Wang XJ, Thibodeau B, Trope M, Lin LM, Huang G. Histologic characterization of regenerated tissues in canal space after the
revitalization/revascularization procedure of immature dog teeth with apical periodontitis. J Endod 2010;34:56-63.
• Wigler R, Kaufman AY, Lin S, Steinbock N, Hazan-Molina H, Torneck C. Revascularization: A Treatment for Permanent Teeth
with Necrotic Pulp and Incomplete Root Development. J Endod 2013 Mar;39(3):319- 26.
• Yilmaz S, Dumani A, Yoldas O. The effect of antibiotic pastes on microhardness of dentin. Dent Traumatol. 2016 Feb;32(1):27-
31.
• Yamauchi N, Nagaoka H, Yamauchi S, Teixeira FB, Miguez P, Yamauchi M. Immunohistological characterization of newly
formed tissues after regenerative procedure in immature dog teeth. J Endod 2011 Dec;37(12):16

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