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)
A'REVITALIZATION'PROTOCOL'LEAD'
TO'DIFFERENT'OUTCOMES'IN'
ADJACENT'TEETH'
)
)
)
ABSTRACT'
)
Regenerative) Endodontic) Procedures) can) be) defined) as) biologically)
based)procedures)designed)to)replace)damaged)structures)including)
dentin) and) cells) of) the) pulp) –) dentin) complex.) The) term)
revascularization) is) more) commonly) employed) with) regenerative)
procedures) and) describes) reintroduction) of) vasculature) in) the) root)
canal) system.) This) case) report) describes) the) treatment) of) two)
nonvital) immature) teeth) with) infected) pulp.) Revitalization) was)
attempted) in) two) adjacent) teeth) by) the) same) operator) following)
similar) protocol.) In) one) of) the) teeth,) revitalization) was) successful)
with)continued)root)wall)thickening,)root)lengthening)and)closure)of)
the) apex) whereas) in) the) adjacent) tooth) though) root) lengthening)
could) not) be) achieved,) a) definite) apical) closure) with) irregular) root)
wall)thickening)could)be)obtained.)
)
'
'
'
'
'
'
'
'
'
'
'
'
'
'
)'
PATEL,)Suhag*) '
ZAFAR,)Salwa**)
KEYWORDS'
SINGH,)Abhishek***)
)
JAIN,)Neetika***)
CHOUDHARY,)Ronak*)
Revitalization.)Regenerative)endodontic)procedures.))
Dentin)complex.)
Department)of)Conservative)and)Endodontics,)Ahmedabad)Dental)College)and)Hospital)Ahmedabad,)Gujarat,)India*)
Department)of)Conservative)and)Endodontics,)Saraswati)Dental)College)and)Hospital)Lucknow,)Uttar)Pradesh,)India**)
Department)of)Conservative)and)Endodontics,)Sardar)Patel)Post)Graduate)institute)of)Dental)and)Medical)Sciences,)Lucknow,)Uttar)Pradesh,)India***)
Correspondence:)[email protected])(PATEL)S))|)Received)19)Jul)2015)Received'in'revised'form)24)Jul)2015)Accepted)29)Jul)2015)
)
809
INTRODUCTION
*
The* reported* outcomes* from* case*
Currently,* for* immature* permanent*
reports* in* various* literatures* showing*
teeth* with* infected* pulp,* regenerative*
c o n t i n u e d* r o o t* d e v e l o p m e n t* a f t e r*
endodontic* procedure* is* the* preferred*
revitalization/regeneration* procedures* are*
treatment* modality.* Regenerative* Endodontic*
variable.* The* success* of* a* case* depends* on*
Procedures* can* be* de=ined* as* biologically*
multiple*factors*which*have*not*been*analyzed*
based* procedures* designed* to* replace*
successfully*till*date.*
damaged*structures* including* dentin*and*cells*
*
of* the* pulp–dentin* complex.1* It* leads* to*
treatment*of*two*nonvital*immature*teeth*with*
increased* root* wall* thickness,* increased* root*
infected*pulp.* Revitalization*was* attempted* in*
length* and* narrowing* of* the* canal* apically*
two* adjacent* teeth* by* the* same* operator*
leading*to*the*formation*of*an*apex.2
following* similar* protocol.* In* one* of* the*teeth,*
*
Though* the* aim* of* the* procedure* is* to*
revitalization* was* successful* with* continued*
attain*an*organized*repair*of*the*dental*pulp,*to*
root* wall* thickening,* root* lengthening* and*
what* extent* the* regeneration* of* the* pulp*
closure* of* the* apex* whereas* in* the* adjacent*
dentin*complex* actually* occurs* is* not* clear* as*
tooth* though* root* lengthening* could* not* be*
yet.*
achieved,* a* de=inite* apical* closure* with*
!
*
The* term* revascularization* is* more*
commonly* employed* with* regenerative*
T h i s* c a s e* r e p o r t* d e s c r i b e s* t h e*
irregular* root* wall* thickening* could* be*
obtained.
procedures* and* describes* reintroduction* of*
vasculature* in* the* root* canal* system.3* But* the*
CASE,REPORT
pulp*space*does*not*contain*only*blood*vessels.*
!
It*also* contains* cells*which*are*required*to* lay*
the*Department* of*Conservative* Dentistry* and*
down* new* vital* tissues.* Few* case* reports*
Endodontics,* Government* Dental* College* and*
where* histological* studies* have* been* carried*
Hospital,* Ahmedabad,* Gujarat,* India* with* a*
out* have* found* pulp* like* loose* connective*
complaint*of*pain*in*upper*left*front*teeth*since*
tissue* in*the* pulp* space* and*ingrowth* of*vital*
past* one* month* with* a* history* of* trauma* 6*
tissues* resembling* cementum,* PDL* and* bone*
months*ago.*Prior*to* his*visit*to* the*college,*he*
from*the*apical*end*of*the*tooth.4*Revitalization*
had* received* incomplete* dental* treatment* by*
is* a* more* appropriate*term* in*such*cases* as*it*
another*local*dentist.*
encompasses* bothM* development* of* new*
*
vasculature*as*well* as* new* vital* tissues* in*the*
central* and* lateral* incisors* were* found* to* be*
pulp*space.2
tender*on*percussion*and*had*root*canal*access*
An* 8MyearMold* male* patient* reported*to*
On* clinical* examination* upper* left*
JRD*M*Journal*of*Research*in*Dentistry,*Tubarão,*v.*3,*n.*4,*sep/oct.*2015
810
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812
becomes* interesting* to* =igure* out* as* to* why*
which* root* canal* infection* was* of* a* long*
this*response*was*seen.
standing*nature.
*
*
The* most* likely* explanation* is* that* the*
But* interestingly,* auto* apexi=ication*
central*incisor*had*a*draining*sinus*suggesting*
resulted* in* the* central* incisor.* Normally*
a* chronic* periradicular* infection* which* was*
apexi=ication*requires*a*very*low*bacterial*load*
absent* in* the* case* of* the* lateral* incisor.* Also,*
in* the* root* canal* space* to* form* a* hard* tissue*
the*central* incisor*was*in*its*later*stage*of*root*
barrier;*possible*explanation*in*the*case*of*the*
development* indicating* a* longer* root/pulp*
central*incisor*is* that*intracanal* application*of*
length* as* compared* to* the* lateral* incisor,*
TAP* sterilized* the* canal* to* an* extent* that* it*
which*is*less*likely*to*promote*root*growth.5
favored*apexi=ication.*
*
*
The*chances* of*survival* of*stem*cells* in*
Human* stem* cell* markers* have* been*
periapical* tissues* decreases* with* the*
s h o w n* t o* b e* i n* s i g n i = i c a n t l y* h i g h e r*
increasing* duration* of* the* periradicular*
concentrations*in*the*blood*clot*induced*inside*
infection;* thus* leading* to* the* lack* of* pulp*
the* root* canal* space* as* compared* to* the*
regeneration* and* poor* root* development* in*
peripheral*blood.6* The*other*explanations*that*
such*cases.
can*be* given*for*the*failure* of* revitalization*in*
This* longstanding* infection* * can* destroy* the*
the* central* incisor* may* be* either* insuf=icient*
cells* capable* of* revitalization* namely,* stem*
bleeding*induced*or*disintegration*of*the*blood*
cells*of*apical*papilla*(SCAP),* dental*pulp*stem*
clot*leading*to*loss* of*scaffold*onto* which*vital*
cells* (DPSC),* periodontal* ligament* stem* cells*
tissue*can*grow.7
(PDLCs),*dental*follicle*precursor*cells*(DFPCs)*
*
and* cells* of* Hertwigs* Epithelial* Root* Sheath*
revitalization* or* a* synthetic* scaffold*
(HERS)* which* migrate* in* response* to* the*
incorporating* antibiotics* and* growth* factors*
signals*by* the*endothelial* cells*and*the*growth*
with*a*suitable*delivery*system*for* continuous*
f a c t o r s* ( V E G F ,* F G F M 2 ) .* A* h o s t i l e*
release* may* have* improved* the* predictability*
microenvironment* in* the* apical* area* may* be*
of* the* procedure* in* relation* to* the* central*
created* which* adversely* affects* growth* factor*
incisor.
secretion*and*hence*in=luencing*the*progenitor*
*
cell* differentiation*into*cells*of*the*pulpMdentin*
electrical* pulp* tester* implying* lack* of*
complex.
innervations* of* the*pulp*space*with* formation*
*
of*some*kind*of*nonspeci=ic*vital*tissue.
However,* this* hypothesis* may* also*
In* such*cases,* a* cell* based* approach*to*
The* two* teeth* did* not* respond* to*
appear* unlikely* in*that* many* cases* have* been*
*
Though*the*current*case*did*not*achieve*
published* with* successful* revitalization* in*
a*conclusive*positive*vitality*response*at*the*18*
JRD*M*Journal*of*Research*in*Dentistry,*Tubarão,*v.*3,*n.*4,*sep/oct.*2015
813
month* follow* up* appointment,* it* is* possible*
5.*Kling* M,*Cvek*M,* Mejàre* I.* Rate*and* predictability* of*
that*on*longer*periods* of*evaluation,* the*teeth*
pulp* revascularization* in* 10* therapeutically*
may*generate*a*positive*response.7,*8
*
It* can* be* said* that* the* current*
reimplanted*permanent*incisors.*Endod*Dent*Traumatol*
1986;2:83–9.
information* on* the* factors* responsible* for*
6.*Lovelace*TW,*Henry*MA,* Hargreaves*KM,* Diogenes* A.*
successful* regenerative* endodontic* treatment*
Evaluation* of* the* delivery* of* mesenchymal* stem* cells*
is*scarce*and*the*outcome*of*the*regenerative/*
revitalization*procedure*is*not*predictable*and*
into* the* root* canal* space* of* necrotic* immature* teeth*
after* clinical* regenerative* endodontic* procedure.* J*
Endod*2011;37:133M8.
needs*to*be*researched*further.
7.* Lenzi* R* and* Trope* M.* Revitalization* Procedures* in*
Two* Traumatized* Incisors* with* Different* Biological*
CONCLUSION
!
Regeneration* of* tissue* in* a* necrotic*
infected*tooth*has*been*thought*until*now*to*be*
impossible.* However,* if* it* were* possible* to*
Outcomes.*J*Endod*2012;38:411M4.
8.* Andreasen* JO,* Bakland* LK.* Pulp* regeneration* after*
nonMinfected*and* infected*necrosis,* what* type* of* tissue*
do*we*want?*A*review.*Dent*Traumatol*2011;28:13M8.
create* favorable* environment* for* growth* of*
tissue,* regeneration* should* occur.* With* the*
current* knowledge,* the* predictability* of*
regeneration*procedures*is*limited;*however*it*
can*be*explored*with*huge*sample*sizes.
REFERENCES
1.* Murray* PE,* GarciaMGodoy* F,* Hargreaves* KM.*
Regenerative* Endodontics,* a* review* of* current* status*
and*a*call*for*action.**J*Endod*2007;*33:*377M90.
2.* Rafter* M.* Apexi=ication:* a* review.* * Dent* Traumatol*
2005;21:1M8.
3.* Law* AS.* Outcomes* of* Regenerative* Endodontic*
Procedures.*Dent*Clin*North*Am*2012;56:627M37.
4.*Wang*X,*Thibodeau*B,*Trope*M,*Lin*L*M,*and*Huang*G*
T.*Histologic*Characterization*of*Regenerated*Tissues* in*
Canal* Space* after* the* Revitalization/Revascularization*
Procedure* of* Immature* Dog* Teeth* with* Apical*
Periodontitis.*J*Endod*2010;36:56–63.
JRD*M*Journal*of*Research*in*Dentistry,*Tubarão,*v.*3,*n.*4,*sep/oct.*2015