ONE STEP PULP

REVASCULARIZATION
TREATMENT OF AN IMMATURE
PERMANENT TOOTH WITH
CHRONIC APICAL ABSCESS: A CASE
REPORT
S. Y. Shin, J. S. Albert & R. E. Mortman
Endodontic Division, Atlantic Coast Dental Research Clinic, West Palm
Beach, FL, USA

2009 International Endodontic Journal

DR.AMITHBABU.C.B
MSCD-ENDO
 INTRODUCTION
 Recently there has been evidence indicating that a
better alternative to conventional calcium hydroxide
apexification exists in immature permanent teeth
exhibiting periapical pathology (Shah et al. 2008).
 Procedures attempting to preserve the potentially
remaining dental pulp stem cells and mesenchyme
stem cells of the apical papilla can result in canal
revascularization and the completion of root
maturation (Sonoyama et al. 2006, Huang et al.
2008
 Revascularization of a partially necrotic pulp in an
immature root is based on the concept that vital
stem cells located in the apical papilla can survive
pulpal necrosis, even in the presence of a
periradicular infection (Huang et al. 2008).
 These stem cells are believed to differentiate into
secondary odontoblasts, ultimately allowing for
dentinal deposition (Huang et al. 2008).
 Survival of the stem cells is aided by an abundant
blood supply to the apical papilla, contributing to
pulp revascularization.
 Furthermore, some of these dental pulp stem cells may have
the capacity to differentiate into odontoblast-like cells,
contributing to root maturation (Yousef 1988, Shah et al.
2008).
 Maintaining the viability of the remaining survived pulp
tissue and the stem cells of the apical papilla are considered
critical for revascularization to succeed.
 Therefore, most recent case reports follow a protocol of no
canal instrumentation throughout the revascularization
procedure in order preserve these essential enduring stem
cells (Iwaya et al. 2001, Chueh & Huang 2006, Jung et al.
2008).
 The literature indicates several advantages of promoting
apexogenesis in immature teeth with open apices
(Murray et al. 2007)
 Revascularization procedures attempt to obtain a longer
and thicker root, whilst restoring vital pulpal
conditions.
 A successfully revascularized tooth would require no
additional treatment.
 Conversely, apexification involves supplementary
treatment visits to replenish the calcium hydroxide and
ultimately requires an apical plug of mineral trioxide
aggregate (MTA) or final Gutta-percha canal filling
(Rafter 2005).
 Although it has been demonstrated clinically that
revascularization procedures can be successful, it is
not completely understood to what extent the
preservation of the apical papilla is involved in final
root maturation (Huang et al. 2008, Shah et al.
2008).
 Continued research is needed to determine if the
stem cells of the apical papilla are irrefutably
responsible for differentiation into odontoblasts and
subsequently accountable for the characteristic
dentinal deposition involved in typical root
maturation (Chueh et al. 2009).
 Drawbacks of the revascularization process include a
lack of long term follow up data on root canal
morphology and pulpal cellular composition
following the procedure on patients.
 This refers to the possibility of accelerated canal
calcification, rendering the tooth more difficult to treat
endodontically in the future (Shah et al. 2008).
 Furthermore, it has not been determined the stage and
duration of pathosis that will ultimately lead to the
complete destruction of the resistant apical
mesenchymal cells and surviving dental pulpstem
cells.
 As a result, it is difficult to case select appropriate
teeth that clinically test nonvital, but maintain
vital apical cells believed to be necessary to
successfully perform the procedure.
 Additional complications such as various
systemic health conditions and immunologic
problems may offer other obstacles in achieving
adequate root maturation in the presence of a
periradicular infection.
 The current case report examines the concept of pulp
revascularization of a mandibular right second premolar via
a single visit treatment approach.
 The objective was to determine if the presented protocol
would result in the formation of a longer and thicker root in
a tooth believed to exhibit a partial loss of vital pulp tissue.
 The resolution of periradicular pathology and related
symptoms was considered essential for a successful
outcome.
 The current case report attempts to provide an utmost
conservative single visit, modified technique to
revascularize a partially necrotic pulp with associated
chronic apical periodontitis
CASE REPORT
 A 12-year-old girl of Hispanic descent was referred
by her general dentist for evaluation and root canal
treatment of the mandibular right second premolar.
 The medical history was unremarkable.

 The patient was scheduled as an emergency visit

with her general dentist 3 days prior, complaining
of pain in the mandibular right premolar region.
 The dentist prescribed amoxicillin 500 mg PO tid.
 The intra-oral exam revealed an
asymptomatictooth 45 with an
associated draining sinus tract located
distal to the root

Vitality, percussion and palpation

exams were performed on the
tooth and adjacent teeth.
Tooth 45 exhibited occlusal
caries with slight palpation and
percussion sensitivity.
 Itdid not respond to 1, 1, 1, 2-tetrafluoroethane
(Endo-Ice; Hygenic Corp., Akron, OH, USA) or
the electric pulp test (Analytic Technology,
Redmond, WA, USA).
 The adjacent teeth were caries free,
asymptomatic and tested vital.
 The periodontal exam presented probings and
physiologic mobility within normal limits.
 RADIOGRAPHIC EVALUATION
 An immature open apex, measuring 2
mm in diameter with a large
periradicular rarefaction
approximately 9 · 9 mm in size,
extending from the apex of tooth 45
to the distal crestal bone area.
 The periapical radiograph
demonstrated a carious lesion
associated with a pre-existing
Oehlers type I dens invaginatus,
where the developmental anomaly
presents an enamel lined invagination
terminating in a blind sac located
within the crown.
 There was visible external inflammatory resorption
on the mid distal portion of the root. Condensing
osteitis was apparent at the periapical area of the
tooth .

 The initial diagnosis of pulpal necrosis with

suppurative chronic periapical abscess was
determined for tooth 45.

 Following local anesthesia administration, rubber

dam isolation and occlusal access preparation
using the dental operating microscope, all
remaining caries and hypo mineralized enamel
were removed.
 Upon entering the coronal aspect of the root canal,
haemorrhage into the pulp chamber was observed
 A size 10 K-file (Kerr, Romulus, MI, USA) was
inserted into the canal and the patient reported
discomfort, potentially indicating the survival of
residual vital pulp tissue.
 The clinical diagnosis was revised from total pulpal
necrosis to partial necrosis.
 After evaluating the treatment options, it was
established that the patient would benefit greatest from
a revascularization procedure.
 A thorough explanation of the potential risks,
complications and benefits of the suggested treatment
was carried out.
 The hemorrhaging coronal portion of the canal was
irrigated with 10 mL of 6% NaOCl and then rinsed with
sterile saline solution.
 The coronal canal was then irrigated with 10 mL of 2%
chlorhexidine gluconate (Vista Dental, Racine, WI,
USA) and left there for 5 min.
 No instrumentation was performed.

 The coronal canal was dried with paper points and

white MTA (Dentsply Tulsa Dental, Tulsa, OK, USA)
was gently packed into the coronal canal .
 A thin layer of thermoplastic Gutta-percha (Calamus system,
Dentsply Tulsa Dental, Johnson City, TN, USA) was temporarily
placed over the MTA to prevent washing out and the chamber
walls were etched with 37% phosphoric acid, rinsed with water
and dried.

 Prior to restoring the access cavity with a final resin-bonded

composite (ESPE Filtek, 3M, St Paul, MN, USA) restoration the
Gutta-percha was removed from the pulp chamber.

 The draining sinus tract was rinsed with 3 mL of 0.12%

chlorhexidine gluconate (Peridex, Zila Pharmaceuticals, Inc,
Cincinnati, OH, USA). The patient was instructed to complete the
amoxicillin provided by her dentist and was prescribed ibuprofen
800 mg for pain.
The placement of white
MTA in the canal

Post-op radiographs
show coronal canal
MTA placement
with a composite
restoration
Final composite restoration
 The patient returned for the 2-week follow-up visit,
asymptomatic with no sensitivity to palpation or biting.
The tooth exhibited minimal sensitivity to percussion. No
significant radiographic changes were noted.
 The smaller sinus tract was irrigated with 3 mL of 0.12%
chlorhexidine gluconate
 At the 6-week recall appointment, the
patient returned asymptomatic.
 Tests for percussion, mobility, palpation
and biting sensitivity were all within
normal limits. The sinus tract had
completely healed and the periapical
radiolucency became less radiolucent

six-week post-op radiograph shows

thickening of dentinal walls with no
evidence of the lamina dura apically
 Clinically, there was a complete re-
establishment of gingival contour( 7-
month recall appointment). The Endo
Ice test and electric pulp test did not
elicit a response.

 The patient returned for the 7-month

post-op visit completely asymptomatic.
Radiographically, the lamina dura
could be traced around the entire root
surface and the periodontal ligament
space was re-established
 At the 13- and 19-month follow-up appointments, the patient
remained asymptomatic.
 No tenderness to percussion or palpation was noted.

 The Endo Ice test and electric pulp test did not elicit a response.

 The radiographs demonstrated evidence of complete periradicular

bone healing and root maturation .
 The 19-month follow-up radiograph showed complete resolution
of condensing osteitis .
 Pre operative Post-op radiograph 2 week recall

6 week recall 7 month recall 19 month recall

 DISCUSSION
 The conventional calcium hydroxide apexification procedure
has been extensively studied and appears to be a reliable
treatment option.
 However, the technique has several disadvantages. These
include a lengthy treatment period, complications relating to
poor patient compliance and resulting thin dentinal walls with a
high risk of long-term root fracture (Cvek & Sundstrom 1974,
Andreasen et al. 2002).
 Contemporary research articles examine alternative treatment
options to encourage a root maturation process emulating
natural root formation, even in the presence of extensive
periapical pathology (Banchs &
Trope 2004, Chueh & Huang 2006, Jung et al. 2008).
 Revascularization treatment has been suggested to be a
favorable alternative, yielding the development of a longer and
thicker root, less susceptible to fracture.
 Using a modified technique, originally outlined by Banchs &
Trope (2004), the current investigation offers a more
conservative single visit approach, avoiding apical irritation
and focuses on preserving the remaining vital pulp tissue and
mesenchymal stem cells of the apical papilla.
 Preservation of these cells is believed to be critical for
successful revascularization (Huang et al. 2008).
 An Oehlers type I dens invaginatus is developmental anomaly
characterized by a hypomineralized, enamel-lined invagination
appearing as a radiolucent blind sac in the crown (Canger et al.
2009).
 Depending on the stage of pathogenesis, treatment options can
vary from preventive and restorative options to nonsurgical root
canal treatment (Er et al. 2007).
 In the present case, tooth 45 appeared radiographically as an
Oehlers type I dens invaginatus, with the formation of an
associated carious lesion and periapical abscess.
 The developmental anomaly and pathology was successfully
treated through the revascularization procedure and final
composite restoration.
 The presented case report used NaOCl and chlorhexidine
irrigation of the coronal necrotic tissue and systemic antibiotics
to provide a favourable environment for pulpal
revascularization to proceed.
 The amoxicillin, prescribed by the general dentist, may have
aided the bactericidal activity in the periapical area.
 The irrigant, 2% chlorhexidine was selected based on its
extended residual anti-microbial properties and a relative
absence of toxicity (Greenstein et al. 1986, Jeansonne & White
1994).
 An in vitro study has reported that root canals treated with 2%
chlorhexidine had 72 h of residual antimicrobial activity
against Streptococcus mutans (White et al. 1997
 Recent questions concerning the use of 2%
chlorhexidine relates to the potential cytotoxicity on
cultured dental pulp stem cells.
 In addition, it has been reported that interactions
between NaOCl and chlorhexidine forms para-
chloroaniline, which is known to be a carcinogen
(Basrani et al. 2007).
 Basrani et al. (2007) suggested that prior to irrigating
with chlorhexidine, it is recommended to wash away
the existing NaOCl to diminish the formation of para-
chloroaniline.
 The current report used copious irrigation of saline
solution to reduce the interaction between NaOCl and
chlorhexidine.
 Mineral trioxide aggregate was used in the study to
provide an effective pulpal seal. Contrary to calcium
hydroxide, MTA exhibits biocompatibility with
adjacent pulp tissue, even capable of inducing pulpal
cell proliferation (Kettering & Torabinejad 1995,
Fridland & Rosado 2005
 There are several advantages of the single visit
revascularization protocol.
 Eliminating subsequent access appointments to the
root canal environment may reduce the possibility of
further bacterial contamination of the canal.
 Single visit procedures also act to diminish the detrimental
consequences of poor patient compliance for regular follow-up
evaluation.
 Decreased successive trauma to the tooth and increased patient
comfort are other potential benefits of completing the treatment in
one visit.
 Previous studies indicate that the revascularized teeth regained
vitality between 15 months to 2 years.
 The current case did not achieve a conclusive positive vitality
response at the 19-month follow-up appointment.
 It is possible that over longer periods of evaluation, the tooth may
generate a positive response
 CONCLUSION
 In conclusion, the presented case report demonstrates a
conservative, single visit revascularization approach, resulting
in the elimination of periapical pathology and a stronger
mature root.
 Whilst the discussion advocates following a more conservative
technique, it is possible that this single visit approach may not
be applicable to all revascularization cases.
 It is believed that with teeth exhibiting complete pulpal
necrosis, the presented protocol would not have succeeded.
 A more aggressive technique may be required to eradicate the
bacteria in the canal system and periapical tissues
 As a result, case selection is critical when deciding which
revascularization protocol is ideal for a particular pulpal
condition.
 Patients that report discomfort to an advancing file within the
canal may indicate the presence of viable canal tissue.
 It is suggested that in these cases, the current technique can be
beneficial prior to attempting the less conservative tri-
antibiotic sequence or calcium hydroxide apexification.
 Further investigation is needed to properly diagnose the
correct pulpal status of a tooth and design treatment guidelines
depending on the stage of pulpal necrosis to obtain a
predictable outcome.
 CRITICAL APPRAISAL
 Where and when was the patient referred ?

 Why did they use 6% Naocl? What is the

significance

 How MTA was placed in the canal ?

 Which technique of rubber dam isolation was done?

THANK YOU