Pulpal Regeneration on a Carious, Immature, Necrotic Molar

Most pulpal regeneration cases are done on traumatically injured anterior teeth.  The following case is a pulpal regeneration on an immature, necrotic tooth #19 due to coronal decay.

This regenerative procedure was done in a single visit, NaOCl irrigation, MTA barriers, flowable composite over MTA and Luxacore resin buildup.  Proper coronal coverage will help preserve this tooth until a permanent crown can be made. No further endodontic therapy is needed on this tooth.

Apexification using Pulpal Regeneration - 2 Yr Results

At Superstition Springs Endodontics, we are leaders in novel endodontic treatments including pulpal regeneration. The traditional treatment for immature roots of CaOH apexification fails to strengthen the root of the tooth and leaves the root more prone to fracture over the lifespan of the tooth. 

Pulpal regeneration allows "pulp-like" tissue to re-grow into the immature root and continue the development of the root. This provides the root with stronger, thicker root walls. Here's another successful case of pulpal regeneration.

 

This young patient had a traumatic incident to tooth #9 5 months earlier. At our initial evaluation, the tooth responded normal to thermal testing. We decided to monitor the tooth over time. At a follow up visit, #9 exhibited no response to thermal testing with an open apex.

Pulpal regeneration was started. Complete pulpectomy was performed with minimal instrumentation to the apex, and irrigation with 5.25% NaOCl. A blood clot was initiated into the canal, a collagen plug was placed and an (white) MTA coronal barrier was placed below the level of the CEJ.

At six month recall, the tooth is asymptomic and functional. The radiograph shows dentinal bridging apical to the MTA placed intracoronally.

 

A sagittal view using CBCT also clearly shows the dentinal bridging below the MTA plug.

At the 2 yr recall of #9, the tooth is asymptomatic, fully functional and orthodontic treatment has been completed.

Are Implants the Future of Dentistry or Just a Step Along the Way?

The real future in medicine and dentistry is in regenerative therapy. While restorative materials including cements, resins, rubbers, metals, titanium etc. are the best materials we currrently have to replace damaged, diseased or missing teeth, the big picture is to replace damaged tissue with regenerated tissues. The dental pulp stem cell has been identified as a source undifferentiated mesenchymal stem cells which may have ability to differentiated into cardio-myocytes, neurocytes, myocytes, osteocytes, chondrocytes and adipocytes. So while our current restorative materials/techniques are the best available in the world, the future of dental care is tissue based rather than titanium based.

While regenerative treatments in dentistry are still years, perhaps decades away, endodontists are beginning to explore this area with what is called pulpal revascularization. This concept of taking a necrotic pulp in an immature root and stimulating revascularization of the pulp canal to allow for continued root development. Yes, I said continued root development. That is a completely new concept.

Here's another case report.


This 9 year old was at home and jumping on the bean bag and someone pulled it away, caught his tooth and completely avulsed tooth #8. It was out of the mouth for 20 minutes and properly replanted by the pediatric dentist.

A couple weeks later, symptoms presented. The tooth was opened, debrided and pasted with Ca(OH)2 paste.

Shortly after (<2 weeks) the tooth was reopened, instrumented lightly to apex, irrigated with 5.25% NaOCl, rinsed with saline and dried with paper point. A file was then used to pierce the periapical tissues to induce bleeding into the canal. An MTA coronal barrier was placed with wet cotton and IRM temporary. PLEASE NOTE THE PA LESION

At 3 month recall the tooth is asymptomatic and pa lesion has resolved.

At 9 month recall the tooth is asymptomatic and fully functional. No percussion pain, normal probings and NORMAL RESPONSE TO EPT. While there is no reaction to thermal testing, there is definitely a normal response to ept.

Looking closely at the radiograph you can see that the dentin walls in the apical portion of the root have thickened and there appears to be dentinal bridging forming in the mid-root area.

While this procedure has also been called pulpal regeneration, some argue that it should be called pulpal revascularization. It is not completely known what type of tissue that is growing into the canal or the source of that tissue (cells from within the canal or migrating in from the periapex). The continued development of the root and healing of the lesion however, is not debatable.

This type of novel treatment may give us a glimpse of the future of dental treatment using tissue regenerative techniques rather than artificial tooth replacement with traditional restorative materials.

For more information regarding the considerations of this procedure, click here.

To see more cases of pulpal revascularization, click here.