Endodontic pulp revitalization in traumatized necrotic immature permanent incisors: Early failures and long‐term outcomes—A longitudinal cohort study

Abstract

Aim This prospective cohort study evaluates clinical and radiographical outcomes of endodontic pulp revitalization (PR) of traumatized necrotic incisors. Methodology Pulp revitalization was performed in 75 traumatized necrotic immature incisors from 71 patients. The radiographic outcome measures were continued root formation (width and length), root resorption, apex closure, periapical index, and root development stage. The clinical outcome measures were percussion pain, palpation pain, pathological tooth mobility, swelling, sinus tract, ankylosis, crown discolouration, response to pulp sensitivity test, and subjective pain. Treatment outcomes were categorized as a success based on the absence of clinical symptoms and when radiographic evidence was present for apical healing and continued root development. The performed statistical tests were repeated measures anova, pairwise comparisons of interactions (t‐test), McNemar's test, and linear regression model. Results In 45 of 75 teeth (60%), PR was successful with the resolution of clinical and radiographic signs and continued root development. PR failed due to the absence of bleeding (n = 19) and persistent infection (n = 11). PR showed statistically significant increases in root length (11%), and dentinal wall thickness (30%), root maturation (pre‐operative 3.38 [CI 1.88; 4.88]; post‐operative 4.04, [CI 2.56; 5.52]) apical closure (71.4%), healing of pre‐operative apical periodontitis (100%), and healing of pre‐operative inflammatory root resorptions (100%). Three predictive variables for continued root maturation were identified – root development stage at entry (p = .0001, β 0.649), [CI 0.431; 0.867], trauma to the soft tissues (p = .026, β −0.012), [CI −0.0225; −0.015], and pre‐operative dentinal wall thickness (p = .009, β −0.001); [CI −0.001; 0.0001]. Conclusions Our findings indicate that PR provides satisfactory clinical and radiographical outcomes in traumatized necrotic incisors. The failed cases were related to lack of bleeding and persistent infections, indicating that new techniques are needed to improve the predictability of PR.

Review of guidance for the selection of regenerative endodontics, apexogenesis, apexification, pulpotomy, and other endodontic treatments for immature permanent teeth

“…The success of regenerative endodontic treatments also including pulp revascularization and revitalization, can vary widely, with a success rate of 60% (Wikström et al, 2022). This suggests the need to adhere to strict case selection criteria to ensure the optimal success of regenerative endodontic procedures can be accomplished.…”

“…Where a patient has swelling, visible lesions, defects and sinus tracks associated with the root canal of an immature tooth, these must first be resolved, drained, disinfected, treated, and sealed to create a long-lasting hermetic barrier prior to regenerative endodontics, to prevent the microleakage of microorganisms into the root canal. This is because a failure to prevent microleakage and a failure to adequately disinfect the root canal will compromise healing and is likely to fail (Wikström et al, 2022). It is possible to provide a regenerative endodontic retreatment if any of these complications occur after the initial treatment, however it must be recognized that the outcomes may be unpredictable (Mohammadi et al, 2021).…”

“…Regenerative endodontics is not always the best choice among all of the available endodontic treatments for traumatized or caries‐affected immature teeth. This is because the clinical failure rates of regenerative endodontics to revitalize immature teeth can be as high as 40% (Murray, 2018; Wikström et al, 2022). Post‐treatment painful and/or severe swelling flare ups can be observed in one‐third of cases, and in almost half of cases, there was no apparent root development and apical closure (Meschi et al, 2021).…”

“…The periapical tissues are instrumented through the open root apical foramen to cause bleeding into the canal to revascularize it. Thereby, promoting tissue formation within the root canal for the continued deposition of mineral to strengthen dentine and grow the roots of immature teeth (do Couto et al, 2021; Namour & Theys, 2014; Wigler et al, 2013; Wikström et al, 2022).…”

“…However, when adult teeth have thick dentinal walls to withstand fracture, providing regenerative endodontics does not provide the adult patient with any reasonable potential benefits. This is because of the greater risk of failure, greater risk of complications, greater risk of a painful flareup, and greater risk that a retreatment will be necessary, due to the success rate being 60% (Murray, 2018; Wikström et al, 2022). In addition to the regenerative potential of adult mature teeth, being extremely limited (Trope, 2008), suggesting the ability for oral tissue regeneration decreases with patient age and maturity.…”