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Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 222-227

Management of bilaterally immature permanent teeth using various treatment modalities

BDS, Saudi Specialty Certificate of Endodontic, SB (Endo), Jeddah, Saudi Arabia

Date of Web Publication25-Jul-2018

Correspondence Address:
Dr. Abdulelah Sameer Sindi
Department of Endodontic, Magrabi Dental Center, P.O. Box 3957, Jeddah 23714
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_29_18

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Management of immature permanent teeth exhibiting symptomatic or necrotic pulp is clinically challenging. Appropriate diagnosis and case selection, and good management, ensure good outcomes. Here, the management of the bilateral, immature, permanent mandibular first molars of a 5.6-year-old male who exhibited reversible pulpitis of the mandibular first right molar (tooth #46) and normal apical tissue and pulpal necrosis with asymptomatic apical periodontitis of the mandibular first left molar (#36) is presented. The former tooth was managed using vital pulp therapy (pulpotomy) and the latter employing revascularization. Follow-up examinations revealed complete formation of the mesial and distal roots of tooth #46, complete formation of the mesial root, but incomplete formation of the distal root of tooth #36, with radiolucency evident within the root.

Keywords: Immature permanent teeth, mineral trioxide aggregate, pulpotomy, revascularization, vital pulp therapy

How to cite this article:
Sindi AS. Management of bilaterally immature permanent teeth using various treatment modalities. Saudi Endod J 2018;8:222-7

How to cite this URL:
Sindi AS. Management of bilaterally immature permanent teeth using various treatment modalities. Saudi Endod J [serial online] 2018 [cited 2021 Sep 25];8:222-7. Available from: https://www.saudiendodj.com/text.asp?2018/8/3/222/237558

  Introduction Top

Management of pulpal damage during root formation poses significant challenges to clinicians. Based on the sensitivity of the affected tooth, two different treatment categories are available: vital or nonvital. Vital pulp therapy (VPT) is preferred as an alternative to root canal therapy if pulp tissue is irreversibly inflamed. Direct/indirect pulp capping and partial or complete pulpotomy are usually performed based on the amount of coronal pulp that must be preserved.[1],[2],[3]

As always, accurate diagnosis is the key to success together with full understanding of the biological processes to be facilitated by treatment. One of the most important factors is the elimination and subsequent prevention of bacterial contamination of exposed coronal pulp tissue, as emphasized by Kakehashi et al.[4]

When the pulp of immature teeth is necrotic, salvage treatment usually features apexification or revascularization. This promotes root development. The discipline of regenerative endodontics was founded by Ostby,[5] who hypothesized that blood clot formation was the first step in healing damaged dental pulp. Since then, the idea of revascularization for the management of immature teeth with nonvital pulp has been developed. The term “revascularization” was employed by Iwaya et al.[6] to describe the clinical healing of periapical abscesses and continued root formation of necrotic immature teeth. Several cases of revascularization, with good outcomes, have been reported. In these cases, root canals of involved teeth were disinfected with triple antibiotic paste (TAP) or calcium hydroxide (Ca[OH]2) before the induction of bleeding.[7],[8],[9] The present case report describes the management of bilateral, immature, permanent first molars with reversible pulpitis on the one side and necrotic pulp on the other.

  Case Report Top

A 5.6-year-old Saudi male child with no relevant medical history sought treatment at the King Abdulaziz University Faculty of Dentistry. According to his father, the chief complaint was that his son had multiple teeth that needed restoration. The patient was referred from the pediatric dentistry department for endodontic evaluation and treatment. Clinical examinations revealed fair oral hygiene but multiple carious and restored teeth. The mandibular first right molar (tooth #46) exhibited occlusal caries, and the mandibular first left molar (#36) had a composite restoration. The cold test (Endo-Ice, Hygenic Corp, Akron, OH, USA) revealed sharp momentary pain in tooth #46 and no response in tooth #36. The patient had no history of spontaneous or prolonged pain. Neither tooth was sensitive to percussion. No swelling or sinus tract or periodontal involvement was noted.

Radiographic examination of tooth #46 revealed an immature apex and a deep occlusal carious lesion [Figure 1] and of tooth #36 exhibited periapical radiolucency around both roots and a deep occlusal carious lesion [Figure 2]. A bitewing radiograph was taken to ensure restorability and revealed that both teeth were indeed restorable [Figure 1]b and [Figure 2]b. A diagnosis of pulpal necrosis with asymptomatic apical periodontitis in tooth #36 and symptomatic reversible pulpitis with normal apical tissue in tooth #46 was made.
Figure 1: Preoperative radiograph of tooth #46 with immature open apex (a). Bitwing film shows the deep carious lesion (b)

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Figure 2: Preoperative radiograph of tooth #36 with immature open apex and apical radiolucency of both roots (a). Bitwing film shows the deep carious lesion (b)

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VPT combined with direct composite restoration and a stainless-steel crown for tooth #46 and revascularization featuring amalgam restoration and a stainless-steel crown for tooth #36 was planned. The treatment plan was discussed with a pedodontist.


Consent form was signed by his father after it was explained other treatment options, possible complications, and possible outcomes. An inferior alveolar nerve block was created by injecting an entire 1.8-mL cartridge of 2% (v/v) lidocaine HCL with 1:100,000 (v/v) epinephrine to anesthetize tooth #46. The tooth was isolated using a rubber dam, and on removal of the caries, the pulp was exposed. Under a digital operating microscope (DOM), a complete pulpotomy using a high-speed and round diamond bur (diameter 1/10 mm, 014) under copious water irrigation was performed. Bleeding was controlled by gently placing a cotton pellet soaked in 5.25% (w/v) sodium hypochlorite (NaOCl) on the pulp stump for 10 min. Then, single-visit, mineral trioxide aggregate (MTA, White Pro-Root MTA, Dentsply, Maillefer, Ballaigues, Switzerland) VPT was performed. The MTA was mixed according to the manufacturer's instructions, and a 4-mm thick layer was gently placed in the pulp chamber, against the wound, using spoon excavators and plastic instruments. The material was molded to the wound and cavity wall using a wet cotton pellet, and the excess was scraped off. A layer of light-cured glass ionomer (Ketac-Fil, 3M ESPE, Seefeld, Germany) followed by bonded resin (a composite) was placed over the MTA [Figure 3]. One week later, the patient reported no symptoms.
Figure 3: Tooth #46 postoperative radiograph after completing the treatment and placement of final restoration

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The second tooth (#36) was anesthetized with 2% (v/v) lidocaine HCL with 1:100,000 (v/v) epinephrine. Rubber dam isolation was placed, and the old composite filling and the recurrent caries were removed. An access cavity was made; three orifices were located under the DOM. The working length was determined by placing a loose file 1 mm shorter than the radiographic apex. Minimal instrumentation was performed using a ProTaper Universal F3 rotary file (Dentsply), and the root canal system was gently irrigated with 20 ml 1.5% (w/v) NaOCl and then saline. The cavity was dried using paper points, and a creamy mixture of Ca (OH)2(Biodinamica, Ibipora, Brazil) was spun down the canal using a Lentulo instrument, to a depth of 6 mm. The access cavity was closed with a cotton pellet and a 4-mm thick layer of a temporary filling material (Cavit; 3M ESPE, Seefeld, Germany).

After 2 weeks, the patient reported no symptoms. Anesthesia was established with 4% (v/v) prilocaine without epinephrine (4% Citanest Plain Dental; Dentsply). A rubber dam was placed and access was regained. The Ca (OH)2 was flushed away and the canals were irrigated with ethylene diamine tetraacetic acid (17%, w/v) followed by saline. The canals were dried using sterile paper points, and bleeding was induced via gentle irritation of the apical tissue using a precurved sterile K-file (#25) placed 2 mm past the apical foramen. A blood clot formed 3 mm below the orifices of the canals, and a 3-mm thick layer of MTA was placed over the clot. A protective glass ionomer layer, followed by amalgam (Amalgam 48, TNMC Medical Devices Ltd., Guildford, UK), was placed over the MTA as a final restoration [Figure 4].
Figure 4: Tooth #36 postoperative radiograph after completing the treatment and placement of final restoration

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At 3-month follow-up, neither teeth exhibited any clinical sign or symptom. The teeth received stainless-steel crown (3M; Unitek, Monrovia, CA, USA) [Figure 5]. At 1-year follow-up, both teeth remained asymptomatic and radiographic examination showed continued root development. Tooth #36 exhibited healing of the apical radiolucent lesion and increases in root wall thickness and length [Figure 6]. At 2-year follow-up, the mesial roots of both teeth exhibited apical closure and the distal root of tooth #46 was almost closed. The distal root of tooth #36 exhibited incomplete closure [Figure 7]. At 3-year follow-up, tooth #46 exhibited apical closure of both roots, but the apical third of the distal root of tooth #36 was not fully closed [Figure 8].
Figure 5: Clinical view of 3-month follow-up. No clinical sign or symptoms and the teeth (#36 and 46) received stainless-steel crown

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Figure 6: One-year follow-up showed continued root development of tooth #46 (a) and #36 (b). Healing of the periapical lesion of #36 and narrowing of the root canals (b)

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Figure 7: Two-year follow-up showed narrowing of the root canals of tooth #46 (a) and #36 (b). The apical third of the distal root of tooth #36 shows incomplete closure

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Figure 8: Three-year follow-up showed complete closure of the root apices of tooth #46 (a). The apical third of the distal root of tooth #36 continued development yet, no complete closure (b)

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  Discussion Top

The management of immature permanent teeth is a difficult challenge in endodontics, commencing at diagnosis and ending with sealing of the root canal system. Electronic pulp testers are insensitive when evaluating young teeth (mature or immature),[10],[11] possibly because of incomplete innervation of the odontoblast layer of immature teeth.[12] Johnsen et al.[13] found significantly fewer myelinated axons in immature premolars with open apical foramina than in older teeth.

Treatment of immature teeth depends entirely on pulp status (vital or necrotic). VPT seeks to save the tooth, allowing completion of physiological development. Bleeding control is the principal factor to consider when selecting a treatment modality.[14],[15] In the present case, direct pulp capping was the initial goal; however, because of diffuse bleeding, the treatment was changed to complete pulpotomy, which was successful. This was preferred to root canal treatment to preserve pulp tissue vitality so that root development could continue.[16],[17]

Bleeding control after removal of inflamed pulp tissue is critical in terms of treatment success, irrespective of the material used or the extent of exposure.[18],[19],[20] In the current case, bleeding was controlled by applying NaOCl before MTA placement as in most reported pulpotomy cases.[21] MTA is biocompatible, does not trigger pulp inflammation, and consistently induces the formation of dentin bridging better than Ca(OH)2.[21],[22],[23],[24]

The success rates of VPT performed after carious exposure range widely (13%–100%),[25],[26] reflecting different methodologies and materials, follow-up periods, examination methods, and success criteria. Accurate diagnosis, complete removal of caries and inflamed pulpal tissue, and bacteria-tight sealing are the major factors affecting outcomes.

Revascularization is another treatment used when the pulp of immature teeth is necrotic. This nonvital treatment of immature permanent teeth seeks to allow continuation of root formation and apical closure.[27],[28] An electronic apex locator (EAL) is useful for defining the working length, with a success rate of 86%.[29] Unfortunately, an EAL is inaccurate before formation of the apical barrier.[30] Therefore, the working length of the present case was estimated based on a parallel preoperative radiograph.[28] Minimal instrumentation was performed during treatment in an effort to minimize pulp infection.[31] A variety of materials have been used to disinfect the canal space, of which TAP and Ca(OH)2 are the most commonly employed.[32] Ca(OH)2 exhibits minimal toxicity toward apical stem cells [33],[34] and triggers release of useful bioactive growth factors from dentin.[35] In terms of removal, 80% of TAP remains within the canal wall whereas only 20% of Ca(OH)2 does,[36] improving stem cell survival and availability. However, Ca(OH)2 is an alkaline; the pH can attain 12, detrimentally affecting periapical stem cells. The benefit of using Ca(OH)2 is achieved when optimally restricted to the coronal half of the tooth, where living stem cells are absent.[37]

Some authors recommend using natural or artificial scaffolds during revascularization rather than relying on blood clots. Sharma and Mittal, in a prospective study, found no significant difference between a blood clot, platelet-rich fibrin, collagen, and poly lactic-coglycolic acid in terms of apical closure.[38]

The criteria for evaluating revascularization success are not yet well established; the outcomes can be viewed from different perspectives. In terms of healing of apical periodontitis, the success rate is 90%–100%.[39],[40] Root width increases by 25%–35.5% and root length increases by 11.3%–14.9%.[37],[39],[41] In one study, tooth survival after revascularization with at least a 6-month follow-up period was 100%.[41] The follow-up times suggested by the American Association of Endodontics guideline (6, 12, and 24 months) were followed up for the current case accordingly.[42]

Three possible explanations of the radiolucency within the distal root of tooth #36 have been proposed which needs histological examination to confirm it. First, five different types of healing were observed by Chen et al.[43] The present case seems to have Type 3 healing “continued root development with the apical foramen remaining open.” Second, revascularization features repair, not regeneration.[44] The tissue formed is not the original pulp tissue. In a histological study, Wang et al.[45] found that the tissue was cementum-like or bone-like and reminiscent of periodontal ligament tissue, attributable to the source of stem cells, contributing to repair. Third, a lateral root apex that is still under development may have an apical foramen that opens laterally.[46] In addition, maturation of an immature open apex may require 3–5 years.[47]

  Conclusion Top

VPT is a viable option when treating immature permanent teeth with vital pulp, allowing conservation of the tissue necessary for continued tooth formation and maturation. Furthermore, revascularization is a useful choice for treating necrotic pulp with an open apex, allowing continued root development, unlike traditional apexification techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient's father has given his consent for his images and other clinical information to be reported in the journal. The patient's father understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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