Case Selection: Tooth with necrotic pulp and an immature apex

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AAE Clinical Considerations for a Regenerative Procedure

These considerations should be seen as one possible source of information and, given the rapid evolving nature of this field, clinicians should also actively review new findings elsewhere as they become available.

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 medicaments and antibiotics necessary to complete procedure.

Informed Consent

  • Two (or more) appointments.

  • Use of antimicrobial(s) .

  • Possible adverse effects: staining of crown/root, lack of response to treatment, pain/infection.

  • Alternatives: MTA apexification, no treatment, extraction (when deemed non-salvageable).

  • Permission to enter information into AAE database (optional).

First Appointment

  • Local anesthesia, dental dam isolation and access.

  • Copious, gentle irrigation with 20ml NaOCl using an irrigation system that minimizes the possibility of extrusion of irrigants into the periapical space (e.g., needle with closed end and side-vents, or EndoVac™). Lower concentrations of NaOCl are advised [1.5% NaOCl (20mL/canal, 5 min) and then irrigated with saline (20 mL/canal, 5 min), with irrigating needle positioned about 1 mm from root end, to minimize cytotoxicity to stem cells in the apical tissues.
  • Dry canals with paper points.

  • Place calcium hydroxide or low concentration of triple antibiotic paste. If the triple antibiotic paste is used: 1) consider sealing pulp chamber with a dentin bonding agent [to minimize risk of staining] and 2) mix 1:1:1 ciprofloxacin: metronidazole: minocycline to a final concentration of 0.1 mg/ml.

  • Deliver into canal system via syringe

  • If triple antibiotic is used, ensure that it remains below CEJ (minimize crown staining).

  • Seal with 3-4mm of a temporary restorative material such as Cavit™, IRM™, glass-ionomer or another temporary material. Dismiss patient for 1-4 weeks.

Second Appointment (1-4 weeks after 1st visit)

  • Assess response to initial treatment. If there are signs/symptoms of persistent infection, consider additional treatment time with antimicrobial, or alternative antimicrobial.

  • Anesthesia with 3% mepivacaine without vasoconstrictor, dental dam isolation.

  • Copious, gentle irrigation with 20ml of 17% EDTA.

  • Dry with paper points.

  • Create bleeding into canal system by over-instrumenting (endo file, endo explorer) (induce by rotating a pre-curved K-file at 2 mm past the apical foramen with the goal of having the entire canal filled with blood to the level of the cemento–enamel junction).

  • Stop bleeding at a level that allows for 3-4 mm of restorative material.
  • Place a resorbable matrix such as CollaPlug™, Collacote™, CollaTape™ or other material over the blood clot if necessary and white MTA/CaOH as capping material.

  • A 3–4 mm layer of glass ionomer (e.g. Fuji IILC™, GC America, Alsip, IL) is flowed gently over the capping material and light-cured for 40 s. MTA has been associated with discoloration. Alternatives to MTA should be considered in teeth where there is an esthetic concern.

    • Anterior and Premolar teeth - Consider use of Collatape/Collaplug and restoring with 3mm of RMGI followed by bonding a filled composite to the beveled enamel margin.

    • Molar teeth or teeth with PFM crown - Consider use of Collatape/Collaplug and restoring with 3mm of MTA, followed by RMGI or alloy.


  • Clinical and Radiographic exam

    • 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)

    • 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.

    • Pulp vitality test

  • The degree of success of Regenerative Endodontic Procedures is largely measured by the extent to which it is possible to attain primary, secondary, and tertiary goals:

    • Primary goal: The elimination of symptoms and the evidence of bony healing.

    • Secondary goal: Increased root wall thickness and/or increased root length. (desirable but perhaps not essential)

    • Tertiary goal: Positive response to vitality testing. (which, if achieved, could indicate a more organized vital pulp tissue)



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