Pulp Revascularization.pptx

Pulp Revascularization

1. Pulp Revascularization of Immature Permanent Tooth with Necrotic Pulp and Open Apex Dr. Hoor-E- Jannath Prity OSD (additional), DGHS DDS Non-Resident, Sylhet MAG Osmani Medical College

2. Introduction Pulp revascularization is a relatively new treatment method for immature necrotic permanent teeth. It induces continued root formation and closure of root apex.

3. Case Selection Tooth with necrotic pulp and an immature apex. Pulp space not needed for post/core, final restoration. Compliant patient/ parent. Patients not allergic to medications and antibiotics necessary to complete procedure.

4. Materials used for irrigation Sodium hypochlorite (1.5-3%) EDTA Normal saline

5. Materials used for disinfection of canal Calcium hydroxide, or, Triple Antibiotic Paste

6. Triple Antibiotic Paste Made by mixing 1:1:1 Ciprofloxacin: Metronidazole: Minocycline to a final concentration of 1-5mg/ml. Alternatives to minocycline: Clindamycin; Amoxicillin; Cefaclor

7. First Appointment Local anesthesia , Rubber dam isolation and Access . Copious, gentle irrigation with irrigating needle positioned about 1mm from root end, to minimize cytotoxicity to stem cells in the apical tissues.

8. First Appointment (cont.) Dry canals with paper points. Place calcium hydroxide or low concentration of triple antibiotic paste. Seal with 3-4mm of a temporary restorative material. Dismiss patient for 1-4 weeks.

9. Second Appointment (1-4 weeks after first visit) Anesthesia with 3% mepivacaine without vasoconstrictor, rubber dam isolation. Copious, gentle irrigation with 20ml of 17% EDTA. Dry with paper points.

10. Second Appointment (cont.) Create bleeding into canal system by over-instrumentation (pre-curved K-file) Stop bleeding at CEJ Allow the blood to clot Place MTA over the clot Restore the tooth

11. Follow-up (6-, 12-, 24- months) Clinical and Radiographic examination No pain, soft tissue swelling or sinus tract (often observed between first and second appointments). Resolution of apical radiolucency (often observed 6-12 months after treatment)

12. Follow-up Increased width of root walls (this is generally observed before apparent increase in root length and often occurs 12-24 months after treatment). Increased root length. Positive pulp vitality test response.

13. Mechanism of Pulp Revascularization Evidences suggest that avulsed immature permanent teeth can be successfully revascularized following reimplantation. In such cases, the necrotic but infected pulp is believed to have acted as a scaffold, permitting the ingrowth of tissue from the periapical area.

14. Requirements for Pulp Revascularization The stem cells arising from dental papilla or apical periodontium Remnants of Hertwig’s root sheath An empty root canal space free of bacteria Scaffold i.e., blood clot/ PRP

15. Advantages of Pulp Revascularization Continued root development. Thickening of the dentinal walls. No risk of root fracture as in case of apexification. Closure of root apex. Restoration of pulp vitality.

16. Disadvantages of Pulp Revascularization Crown discoloration. Development of resistant bacterial strains. Allergic reaction to the medication.

17. Causes of Unfavorable outcomes Failure to induce any bleeding; which might be due to- Resolution of inflammation Use of local anesthetics with vasoconstrictors

18. Conclusion Teeth that have undergone pulp revascularization have better prognosis than teeth that received apexification treatment. With thicker and longer roots, risk of fracture of the tooth decreases. This treatment modality should be preferred to conventional apexification procedure.

19. References Nagy MM, Tawfik HE, Hashem AA, Abu- Seida AM. Regenerative potential of immature permanent teeth with necrotic pulps after different regenerative protocols. J Endod . 2014 Feb;40(2):192-8. Nosrat A, Seifi A, Asgary S. Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial. J Endod 2011 Apr;37(4):562-7. Review. Petrino JA, Boda KK, Shambarger S, Bowles WR, McClanahan SB. Challenges in regenerative endodontics: a case series. J Endod 2010 Mar;36(3):536-41. Reynolds K, Johnson JD, Cohenca N. Pulp revascularization of necrotic bilateral bicuspids using a modified novel technique to eliminate potential coronal discolouration: a case report. Int Endod J. 2009 Jan;42(1):84- 92. Rodríguez-Lozano FJ, Bueno C, Insausti CL, Meseguer L, Ramírez MC, Blanquer M, Marín N, Martínez S, Moraleda JM. Mesenchymal stem cells derived from dental tissues. Int Endod J. 2011 Sep;44(9):800-6.

20. References Vishwanat L, Duong R, Takimoto K, Phillips L, Espitia CO, Diogenes A, Ruparel SB, Kolodrubetz D, Ruparel NB. Effect of Bacterial Biofilm on the Osteogenic Differentiation of Stem Cells of Apical Papilla. J Endod . 2017 Jun;43(6):916-922. Wang XJ, Thibodeau B, Trope M, Lin LM, Huang G. Histologic characterization of regenerated tissues in canal space after the revitalization/revascularization procedure of immature dog teeth with apical periodontitis. J Endod 2010;34:56-63. Wigler R, Kaufman AY, Lin S, Steinbock N, Hazan-Molina H, Torneck C. Revascularization: A Treatment for Permanent Teeth with Necrotic Pulp and Incomplete Root Development. J Endod 2013 Mar;39(3):319- 26. Yilmaz S, Dumani A, Yoldas O. The effect of antibiotic pastes on microhardness of dentin. Dent Traumatol . 2016 Feb;32(1):27-31. Yamauchi N, Nagaoka H, Yamauchi S, Teixeira FB, Miguez P, Yamauchi M. Immunohistological characterization of newly formed tissues after regenerative procedure in immature dog teeth. J Endod 2011 Dec;37(12):16