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    Case Report/Clinical Techniques


    iologically Based Treatment of Immature Permanent eeth with Pulpal Necrosis: A Case Series

    l-Young Jung, DDS, MS,* Seung-Jong Lee, DDS, MS,* and Kenneth M. Hargreaves, DDS, PhD†

    A p p i a i w r

    r c g t i r h n k H o s e r

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    bstract his case series reports the outcomes of 8 patients ages 9 –14 years) who presented with 9 immature ermanent teeth with pulpal necrosis and apical peri- dontitis. During treatment, 5 of the teeth were found o have at least some residual vital tissue remaining in he root canal systems. After NaOCl irrigation and edication with ciprofloxacin, metronidazole, and mi- ocycline, these teeth were sealed with mineral trioxide ggregate and restored. The other group of 4 teeth had o evidence of any residual vital pulp tissue. This econd group of teeth was treated with NaOCl irriga- ion and medicated with ciprofloxacin, metronidazole, nd minocycline followed by a revascularization proce- ure adopted from the trauma literature (bleeding voked to form an intracanal blood clot). In both groups f patients, there was evidence of satisfactory postop- rative clinical outcomes (1–5 years); the patients were symptomatic, no sinus tracts were evident, apical eriodontitis was resolved, and there was radiographic vidence of continuing thickness of dentinal walls, api- al closure, or increased root length. (J Endod 2008;34: 76 – 887)

    ey Words ndodontics, immature permanent tooth, open apex, egenerative, revascularization, stem cell

    From the *Department of Conservative Dentistry, Yonsei niversity School of Dentistry, Seoul, Korea; and †Department f Endodontics, University of Texas Health Science Center at an Antonio, San Antonio, Texas.

    Address requests for reprints to Dr Seung-Jong Lee, De- artment of Conservative Dentistry, Yonsei University School f Dentistry, 134 Shinchon-Dong, Sudaemun-Ku, Seoul, Korea 20-752. E-mail address: 099-2399/$0 - see front matter

    Copyright © 2008 American Association of Endodontists. oi:10.1016/j.joen.2008.03.023


    76 Jung et al.

    lthough contemporary nonsurgical endodontic procedures confer high degrees of clinical success (1, 2), the root canal system is obturated with synthetic materials,

    reventing any of the advantages that might ensue by regeneration of a functional ulp-dentin complex (3). This is a particular problem when treating the necrotic but mmature permanent tooth, where conventional treatment often leads to resolution of pical periodontitis, but the tooth remains susceptible to fracture (4) as a result of nterruption of apical and dentinal wall development. Thus, one alternative approach ould be to develop and validate biologically based endodontic procedures designed to

    estore a functional pulp-dentin complex. For more than 50 years, clinicians have evaluated biologically based methods to

    estore a functional pulp-dentin complex in teeth with necrotic root canal systems aused primarily by trauma or caries. Although case series from the 1960s–1970s in eneral were not successful in producing this outcome (5, 6), it should be appreciated hat they were performed without contemporary instruments or materials and without nsight generated from the trauma or tissue engineering fields (7). More recent case eports, published during the last 15 years, have demonstrated that it is possible in umans to restore a functional pulp-dentin complex in the necrotic immature perma- ent tooth (8 –13). Human histologic studies have not yet been reported, so it is not nown whether these treatments truly recapitulate the normal pulp-dentin complex. owever, these case studies provide some measure of achieving satisfactory functional utcomes, because postoperative recalls indicate that the patient is asymptomatic, no inus tracts are present, apical periodontitis is resolved, and there is radiographic vidence of continuing thickness of dentinal walls, apical closure, or development of oot length.

    Although case series do not provide definitive evidence to support a given treat- ent modality, they do have the advantage of being conducted in actual patients and thus

    rovide greater insight than preclinical studies. Moreover, the results from case series an be used to identify potentially important parameters that can guide the design of uture prospective clinical trials. For example, in nearly all published case series on ulpal regeneration, an effort was made to evoke an intracanal blood clot to trigger

    issue ingrowth. In this case series, we report conditions in which it was not necessary o evoke intracanal bleeding to have continued root development.

    Pulp Regeneration without Formation of a Blood Clot ase 1

    A 10-year-old girl was referred to the Department of Conservative Dentistry of the ental Hospital of Yonsei University by an oral and maxillofacial surgeon for evaluation n the right second mandibular premolar (tooth #29). The girl had a history of swelling f the right mandibular buccal vestibule, for which she received an incision for drainage rocedure at the Department of Oral and Maxillofacial Surgery 2 months earlier. On linical examination, the patient was slightly symptomatic to percussion, and a sinus ract was present that traced to the apex of tooth #29. The first and second premolars ere free of caries, but a fracture of an occlusal tubercle of tooth #29 was noted on

    isual inspection. Periodontal probings were within normal limits for all teeth in the ower right region. Diagnostic testing was inconclusive on cold and electric pulp testing, ut the patient reported sensitivity to percussion or palpation. Periradicular radio- raphic examination revealed that tooth #29 had an incompletely developed apex and periradicular radiolucency (Fig. 1A). The diagnosis of pulp necrosis and chronic

    pical abscess with a sinus tract was made for tooth #29.

    JOE — Volume 34, Number 7, July 2008

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    Case Report/Clinical Techniques


    igure 1. (A) Radiographic image showing an incompletely developed apex and a periradicular radiolucency of tooth #29. Note the sinus tract that traces to the apex f tooth #29. (B) Radiographic view presenting a gutta-percha cone tracing to tooth #29, and a periradicular radiolucency associated with tooth #28. (C) Radiograph rom 60-day follow-up visit after both teeth were medicated with triantibiotic paste. The sinus tract is still traced to the apex of tooth #29. The thickness of temporary illing material does not seem to be appropriate for both teeth. (D) The radiograph demonstrating complete resolution of the radiolucency and continued development

    f the apex of both teeth at 6-month follow-up. (E) Follow-up at 5 years.

    OE — Volume 34, Number 7, July 2008 Biologically Based Treatment of Immature Permanent Teeth with Pulpal Necrosis 877

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    Case Report/Clinical Techniques


    When the access cavity was made under rubber dam isolation, a urulent hemorrhagic exudate discharged from the canal. The tooth as left open until the discharge of the exudate had stopped. After

    he exudate had almost stopped, a K-file was inserted into the canal. he patient did not complain of any sensation until the file tip was in the iddle part of the canal. In addition, a little resistance by residual tissue as felt in the mid-portion of the canal, and the patient had a sensation f pain at that time. On the basis of these findings, the possibility was aised that at least some vital pulp tissue remained in the canal, and herefore we used a method similar to that reported by Iwaya et al. (8) n an attempt to achieve regeneration of the pulp tissue complex. The oot canal was irrigated with 5% NaOCl for 10 minutes and dried with aper points, and a mixture of ciprofloxacin, metronidazole, and mi- ocycline paste as described by Hoshino et al. (14) was introduced into he canal with a lentulo spiral. The access cavity was closed with Caviton GC, Aichi, Japan). No mechanical instrumentation was performed dur- ng the procedure.

    The patient returned a week later, asymptomatic, reporting no ain postoperatively. However, the sinus tract was still present. The ccess cavity was opened, and the root canal was slowly flushed with 10 L of 5.25% NaOCl, and irrigation was continued for 15 minutes. Unlike

    he first visit, a mixture of erythromycin and Ca(OH)2 was placed into he root canal. The patient returned 2 weeks later. The sinus tract was till present, and the patient complained of slight discomfort in tooth 28. A size #30 gutta-percha cone was threaded into the opening of the inus tract, and a periapical radiograph was taken. Radiographic exam- nation showed that a sinus tract was traced to the apex of tooth #29, and periradicular radiolucency was suspected around tooth #28 (Fig. 1B). he clinical examination revealed that moderate percussion pain was ssociated with teeth #28 and #29. Diagnostic testing was inconclusive n cold and electric pulp testing on tooth #28. A diagnosis of pulp ecrosis and chronic apical periodontitis was made for tooth #28.

    An access cavity was made on tooth #28, and the necrotic nature of he upper part of the root canal was confirmed. However, some vital ulp ti