PULP REVASCULARIZATION

K.SUSHMITHAFINAL YEAR

CONTENTS

WHAT IS REGENERATION ????

AND REGENERATIVE ENDODONTICS???

Regenerative endodontic procedures are biologically based procedures, designed to replace damaged structures

including dentin and root structures as well as the cells of pulp dentin complex.

INTRODUCTION:Human immature permanent tooth is a

developingOrgan, any trauma, carirs, anatomical anomaly etc Leading to pulpal necrosis, leaves us with the

following:

Open apexShort apex Infected pulp with blunder bass canalsFragile and weak dentinal wallsAnd in short the tooth ceases to grow.

TREATMENT OPTIONS: 1.Apexification2.Apexogenesis 3. A newer advancement _

Revascularization of pulp.

REQUISITES FOR SUCCESSFUL TREATMENT: Young patients _ tremendous healing potential.Open apex allows in growth of tissues.Multipotent differentiation of MSC’s.Creating a proper environment conducive for regeneration.Use of growth factors, scaffolds, signalling

molecules.

OBJECTIVES:To achieve continous root end development

and gain apical closure ensuring a proper crown and

root and a natural apical seal.Strengthen dentinal walls, thus attaining normal

fracture resistance.Regenerate the cells of pulp _ dentin complex.

POTENTIAL TECHNOLOGIES OF REGENERATIVE ENDODONTICSa. Root canal Revascularizationb. Post natal stem cell therapy

_pulp implantation _scaffold implantation _injectable scaffold

delivery _3d cell printing c. Gene delivery.

REVASCULARIZATION IS THROUGH:

a. By inducing blood clot

b. By PRF

STEPS IN REVASCULARIZATION

1.DISINFECTION OF THE ROOT CANAL

2. PROVISION OF A SCAFFOLD

3. CORONAL SEALING.

DISINFECTION OF THE ROOT CANAL SYSTEM:

Mainly by irrigation with sodium hypochlorite (NaOCl) 20 ml /canal and cholrhexidine followed by

disinfection with anti microbial dressings. Best anti microbial dressing is :Triple antibiotic paste. What is triple antibiotic paste ????? It is a 1:1:1 combination of ciprofloxacin,

metronidazole and minoxylin. This paste is placed into the canal and left it for 21 days,

it renders the canal sterile.

PROVISION OF A SCAFFOLDPrior to this step, copious, gentle irrigation

with EDTA is recommended because it prevents biofilm formation and encourages pulp –dentin

complex regeneration.The suggested protocol for providing a scaffold

is theintroduction of a sterile #20 precurved k_ file

2mm past the apical foramen to allow the entire

canal to fill entire canal to fill with blood to the level of

cemento _enamel junction.

Bleeding should be controlled using pressure applied with a cotton pellet soaked in sterile saline until a clot has formed.This should occur with in 15 mins.Bleeding and clot formation, the initial steps in tissue healing, lead to granulation tissue formation, an essential component of both regenerative and reparative healing.

LIMITATIONS:This technique is limited by the

unpredictability of both the concentrations and the composition

of the cells trapped in the clot, as tissue engineering requires effective concentrations and

composition of cells to restore function.In addition few authors reported cases in

which it was not possible to produce bleeding in a canal.

The above mentioned concerns have prompted researches to look for better scaffolds that can be

constructed regardless of whether or not bleeding can

be evoked. The use of fibrin matrices such as

platelet_rich plasma and platelet rich fibrin has been

widely reported in this regard.

PRF is a second generation platelet concenterate is anautologous fibrin mesh that serves as a reservoir for slow, contious release of growth factors.

PRF , is essentially, nothing more than centrifused blood taken from the same patient.

This PRF when introduced into the apical area the HERSsignals the pluripotent stem cells of the periodontal ligament to differentiate into cementoblasts and Odontoblasts and cells of pulp _dentin complex.

CORONAL SEALOnce a scaffold has been produced with in the

canal, a bacterial seal is indicated. The material used for this purpose currently is

MTA

MTA is a bioceramic material capable of setting even in

the presence of blood.Once it is set, it is highly resistant to bacterial penetration.To prevent over extension of MTA a collagen

matrix such as colla plug is placed at the orifice.Another newer material used for the same purpose

is Biodentine and Bioaggregate.

Factors influencing:

Age of the patient.

Disinfection of the root canal.Apical diameter.

Advantages:

Technically simple and can be completed using currently available instruments and medicaments without expensive biotechnology.

Regeneration of tissue in root canal systems by a patient’s own blood cells avoids the possibility of immune rejection and pathogen transmission from replacing the pulp with a tissue engineered construct

OUT COMES OF REVASCULARIZATION THERAPIES:Can be evaluated at four level.

1.Clinical evidence of periapical healing: This includes

absence of sensitivity to percussion . 2.Radiographic evidence of periapical healing and

root Development: this includes complete osseous healing

of the periapical lesion