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Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 210-216

Outcome of vital pulp therapy, revascularization, and apexification procedures: A retrospective study

Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission10-Dec-2021
Date of Decision07-Feb-2022
Date of Acceptance08-Feb-2022
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Mey A Al-Habib
Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, P.O. Box: 80200, Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sej.sej_239_21

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Introduction: Vital pulp therapy (VPT), revascularization, and apexification are different endodontic treatment modalities that aim to preserve tooth structure and decrease bacterial leakage increasing the long-term success of the treatment. The study aims to report the outcome of VPT, revascularization, and apexification procedures treated teeth in the endodontic department at King Abdulaziz University Dental Hospital performed by faculty and postgraduate residents.
Materials and Methods: Thirty-three cases of VPT, revascularization, and apexification cases were evaluated. The outcome was assessed depending on the patient's signs and symptoms, healing of the apical periodontitis, and the signs of continued root development.
Results: The overall results have shown that 60% of the cases were healed completely, 30% presented with incomplete healing, and 10% failed during the follow-up period and required further intervention.
Conclusion: It has been concluded that the outcomes of VPT, revascularization, and apexification were fairly high as they favored healing of periapical periodontitis and root maturation with presentation of no signs and symptoms.

Keywords: Apexification, pulp capping, regeneration, revascularization, vital pulp therapy

How to cite this article:
Al-Habib MA. Outcome of vital pulp therapy, revascularization, and apexification procedures: A retrospective study. Saudi Endod J 2022;12:210-6

How to cite this URL:
Al-Habib MA. Outcome of vital pulp therapy, revascularization, and apexification procedures: A retrospective study. Saudi Endod J [serial online] 2022 [cited 2023 Mar 26];12:210-6. Available from: https://www.saudiendodj.com/text.asp?2022/12/2/210/343555

  Introduction Top

One of the main challenges associated with endodontic treatment procedures includes the treatment of infected immature permanent teeth with wide canals, thin dentinal walls, and open apices. These characteristics of immature permanent teeth cause difficulty for the practitioner in instrumentation, determining the working length, and controlling irrigants/obturation materials.[1] Endodontically treated immature permanent teeth tend to have a poor long-term prognosis as they are more prone to fracture due to incomplete root development and weak dentinal walls.[2] Historically, a necrotic tooth with an open apex was treated with intracanal calcium hydroxide (Ca[OH] 2) that required multiple visits to the clinic over an extended time period.[1] One of the adverse effects of long-term placement of Ca(OH)2 is that it changes physical properties of dentin resulting in reduction of the root strength.[3],[4] Therefore, another treatment that involved the use of an apical barrier placing a biocompatible material such as mineral trioxide aggregate (MTA) was proposed as a substitute to apexification with Ca(OH)2.[5] However, MTA apexification does not improve the root strength, increase thickness of the root canal walls, or allow physiological apical closure, despite the advantage of fewer number of visits.[6]

Vital pulp therapy (VPT) involves the elimination of local irritants followed by placement of a protective material over the pulp in vital permanent teeth.[7] Direct and indirect pulp capping and pulpotomy are different treatment modalities of VPT. The reversible pulpal injury is treated with VPT as it promotes root development, apical closure, and accomplishment of complete root canal therapy.[8] Studies have shown promising results for pulp capping of cariously exposed mature permanent teeth using MTA and Biodentine.[9] The results showed no significant differences in the overall success rate of both the MTA and Biodentine. Moreover, they are likely to have favorable and comparable success rates, when they are used as pulpotomy material for treating the permanent teeth being exposed to dental caries. However, the long-term success of VPT relies primarily on the amount of tooth structure remaining and the coronal restoration integrity.[9]

Immature vital permanent teeth with exposed coronal pulps by either caries or traumatic injury may be treated with pulpotomy. Pulpotomy involves the removal of the coronal portion of a vital pulp as a mean of maintaining the vitality of the remaining radicular portion. The pulpotomy materials used with successful clinical efficacy include ferric sulfate, Ca (OH) 2, and MTA. A study has shown that MTA is considered among the successful bio-regenerative treatment of primary molars.[10] Both MTA and Biodentine are calcium silicate-based materials that possess bio-inductive and regenerative capabilities. This formulation has attracted many dental practitioners to use it because of its increased biocompatibility and robust mechanical properties.[11]

Another treatment supporting the ingrowth of tissues into the pulp canal space and root formation is known as revascularization. This treatment follows a customized disinfection technique that stimulates bleeding from the periapical tissues leading to a blood clot formation in the canal. This blood clot acts as a scaffold carrying stem cells and growth factors from the apical papilla to the pulp canal.[12] Previous studies have reported variable revascularization results such as increased root width, length, and apical closure.[13],[14],[15],[16],[17] Histological studies that investigated the nature of the newly formed hard tissues revealed that it mostly resembles the periodontal ligament tissue due to the heterogeneous nature of the cells that fill the canal of vascularized immature teeth.[18]

The treatment of revascularization was recently termed a regenerative endodontic procedure. The copious diluted irrigation, creation of sterile blood clot inside the pulp space, and placement of antibiotic pastes are used as common aspects included in the regenerative modalities of canal disinfection. The traumatic avulsed and replanted immature teeth provided understanding of the concept of pulp regeneration.[19] The reasons causing apexogenesis in the infected immature permanent teeth can be allocated to the presence of mesenchymal stem cells, which are multipotent dental pulp stem cells.[19] The etiology and histopathological events taking place during the regenerative process have not been investigated thoroughly. Therefore, it is important to evaluate the outcomes of VPT, revascularization, and apexification procedures that would be helpful for the dental practitioners in choosing the best treatment modality.

VPT, revascularization, and apexification treatments need to be accompanied by an overlying tight-sealed restoration as it decreases bacterial leakage from the restoration-dentin interface increasing the long-term success of the treatment.[20] There are many controversies about pulp status before and after VPT, revascularization, and apexification treatments.[2],[21],[22],[23],[24]

Moreover, there is no consensus on the management of cariously exposed permanent teeth as to which is the best therapeutic treatment.[25],[26],[27]

This present retrospective case series aims to assess the outcome of VPT in immature vital permanent teeth and endodontic treatment performed in the immature necrotic permanent teeth through revascularization and apexification.

  Materials and Methods Top

The residents and faculty members at the endodontic department of King Abdulaziz University were requested to submit the cases of VPT, revascularization, and apexification that have been treated by them between 2018 and 2020. The study protocol has been approved by the Research Ethical Committee at King Abdulaziz University (No. 86-11-19). This research has been conducted in full accordance with the World Medical Association Declaration of Helsinki. All data sets were anonymized and de-identified prior to analysis.

The clinical records obtained from the electronic dental charts were evaluated for eligibility for the study using certain inclusion and exclusion criteria. The inclusion criteria for this study were immature permanent teeth with necrotic or inflamed pulp with a preoperative, postoperative, and at least a 3-month follow-up radiograph after the treatment with documented progress notes of clinical signs and symptoms of each endodontic appointment. It was assured that all the included participants had completed the respective endodontic treatment following the prescribed clinical protocol and that final restoration has been placed. The exclusion criteria for this study were the cases with missing or incomplete clinical records. Among the 43 reported cases, 33 cases have been chosen for this study based on the inclusion criteria with an age range of 9–46 years. Eighteen vital roots were treated by VPT, eight necrotic immature roots were treated by revascularization, and seven necrotic roots were treated by apexification.

A standard electronic form designed to collect information was used for collecting data. The data included preoperative signs and symptoms, details of clinical treatments including type of material used, and other treatments rendered on the affected tooth.

As this was a retrospective study, a specific clinical protocol was not implemented prior to performing the treatments. Residents under the supervision of endodontic faculty performed all cases.

VPT included direct, indirect pulp capping and pulpotomy using Ca(OH)2 or MTA as a capping material following standard VPT protocols. Revascularization cases followed the recently published AAE clinical guidelines for revascularization.[28] The treatment was done in multiple visits (2–3). The first appointment consisted of local anesthesia, rubber dam isolation, access cavity, working length determination, and irrigation with varying 3% sodium hypochlorite and EDTA with minimal or no instrumentation. Intra-canal medicaments (Ca[OH]2) were used for varying durations. The last appointment before completion of revascularization consisted of local anesthesia without epinephrine, rubber dam isolation, irrigation to remove remaining intra-canal medication and laceration of the apical tissue in an attempt to induce bleeding into the canal. Finally, all cases used MTA placed at approximately the level of cementoenamel junction, followed by placement of a resin bonded restoration. In apexification procedures, standard irrigants and instrumentation were utilized, and Ca(OH)2 was used as an intra-canal medication between visits for varying durations. All cases were completed in multiple visits (2–3). MTA was placed in the apical portion of the canal, and the remaining canal system was obturated with thermoplasticized gutta percha and AH Plus sealer.

The outcome of these treatments was assessed as follows:[11],[16]

  • Complete healing – no inflammatory clinical signs and symptoms, complete resolution of periradicular radiolucency, increase in the root dentin thickness/length, and apical closure
  • Incomplete healing – the absence of inflammatory clinical signs and symptoms, the periapical lesion completely healed without any signs of root maturation or thickening, the periapical lesion is either reduced in size or unchanged with/without radiographic signs of increasing root dentin thickness/length, or apical closure
  • Failure – persistent inflammatory clinical signs and symptoms and increase in the size of periradicular lesion.

The primary outcomes of all the procedures were evaluated based on the survival, clinical success, and adverse events. Data were presented as percentages of healed, incomplete healing, and failed.

  Results Top

The study results have shown that 60% of the cases healed completely, 30% were presented with incomplete healing, and 10% failed during the follow-up period and required further treatment [Table 1].
Table 1: Summary of variables and treatment outcome provided to the patients

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VPT is considered an ultra-conservative treatment in modern endodontics.[29],[30] Therefore, this current study has focused on the outcomes of VPT in different cases (6 cases of indirect pulp capping, 4 cases of DPC, and 8 pulpotomy cases). Twelve of 18 cases of VPT (67%) healed completely; 2 cases (11%) failed during the observation period where pulpitis or pulp necrosis happened and required further treatment; the other 4 cases (22%) showed incomplete healing with incomplete apical closure and were rescheduled for follow-up visits. [Figure 1] illustrates the complete healing of VPT procedure (MTA pulpotomy) of a lower left 1st permanent molar. The patient was asymptomatic for 14 months after completing the treatment.
Figure 1: Complete healing of vital pulp therapy procedure (mineral trioxide aggregate pulpotomy) of a lower left 1st permanent molar; (a) preoperative radiograph; (b) postoperative radiograph; (c) follow-up radiograph at 2 months; (d) follow-up radiograph at 14 months

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The treatment of revascularization favors the continuation of root development promoting the closure of apical foramen and thickening dentinal walls. Based on the criteria previously stated, 4 of 8 cases (50%) healed completely; 1 case (12%) failed during the observation period with persistent inflammatory clinical signs and symptoms and increased size of the periradicular lesion which required further treatment; and another 3 cases (38%) showed incomplete healing with incomplete apical closure and were rescheduled for follow-up visits. [Figure 2] shows complete healing after revascularization treatment of lower right 2nd permanent molar. The patient was asymptomatic for 2 years after completing the treatment. Whereas, [Figure 3] illustrates the failure of revascularization procedure of a lower left 2nd permanent molar. The patient, who underwent this treatment was symptomatic with increased size of the periradicular lesion within 9 months of the treatment.
Figure 2: Complete healing of revascularization procedure of lower right 2nd permanent molar; (a) and (b) preoperative radiographs; (c) postoperative radiograph; (d) follow-up radiograph at 24 months

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Figure 3: Failure of revascularization procedure of a lower left 2nd permanent molar; (a) and (b) preoperative radiograph; (c) postoperative radiograph; (d) follow-up radiograph at 9 months

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Apexification is a treatment procedure for treating and preserving immature necrotic permanent teeth to induce a calcified barrier in a root with an open apex or an incompletely formed root. Four of 7 cases (57%) healed completely; and another 3 cases (43%) showed incomplete healing with incomplete resolution of periapical radiolucency and were rescheduled for follow-up visits while no cases failed during the observation period [Supplementary Table 1]. [Figure 4] illustrates an apexification procedure of an upper right lateral incisor. The patient was asymptomatic with healed periapical radiolucency 2 years after completing the treatment.

Figure 4: Complete healing after apexification procedure of an upper right lateral incisor; (a) preoperative radiograph; (b) apical mineral trioxide aggregate plug radiograph; (c) postoperative radiograph (d) follow-up radiograph at 24 months

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  Discussion Top

The present case series has focused on the treatment outcomes of different endodontic procedures including the VPT, revascularization, and apexification procedures. Studies have shown that the success of VPT significantly depends on the increased probability of performing optimal root canal therapy.[2],[26],[31] In the present study, the complete healing of VPT procedure (MTA pulpotomy) was observed in a 1st permanent molar, in which the patient was asymptomatic for 14 months after completing the treatment. A study done by Ashraf et al. assessed the success rate of using calcium-enriched mixture[32] and Biodentine in apexogenesis for treating immature permanent molar with irreversible pulpitis and vital maxillary central incisor. The results showed satisfactory outcomes regarding the usage of calcium-enriched mixture cement and Biodentine in VPT cases. It is also important to provide a bacteria-free environment after tooth restoration and healing to indicate the support for the ongoing healing within the pulp.[33]

The procedure of revascularization uses manual instruments and auxiliary chemical substances that are followed by final coronal restoration. This procedure renders recovery of the pulp vitality through continuous root development for immature necrotic teeth, with biological means; contrary to the artificial apical barrier techniques. Nagata et al. presented the significance of revascularization as a valid treatment option for an immature necrotic tooth. The results depicted successful treatment outcome in the treatment of an immature tooth with periapical lesion as the tooth was presented asymptomatic and lesions resolved clinically and radiographically. These results clarified the fact that revascularization plays a significant role in the thickening of the dentin walls which prevents tooth weakening and fracture.[34] Another similar study conducted by Shah et al. assessed the efficacy of revascularization of infected immature teeth. The results showed that none of the individuals complained of pain, enlargement of preexisting apical pathology, or reinfection, representing a favorable outcome of revascularization.[35] These results were consistent with the present study as it showed complete healing after revascularization treatment of upper right central incisor. Moreover, the patient was asymptomatic for 2 years after undergoing revascularization. The number of teeth evaluated in the present study was low, which is similar to those in previously published retrospective cohort studies.[1],[36]

In the present study, the healing of an upper right lateral incisor after apexification procedure showed promising results after 24 months of completing the treatment. A similar study considered nonvital immature permanent teeth for evaluating the clinical and radiographic outcomes after undergoing apexification procedure.[37] The study also investigated the factors that affected the treatment outcome as success of functional retention. The results presented a success rate of 80.77% for apexification procedure, whereas the main cause of failed cases was fracture. There is an increased chance of failed cases with signs and symptoms of apical periodontitis as a result of persistent infection.[37] Damle et al. conducted a comparative study between MTA and Ca(OH) for apexification of anterior teeth. The results showed a better success rate of MTA for apexification. This procedure is advantageous as it requires less time, biocompatible, possesses great sealing ability, and provides a barrier for direct obturation. However, apexification procedure does not provide satisfactory results for further root development.[38]

The reasons for the failures of the procedure were also investigated; some cases showed coronal leakage because of restorative failure, which could have potentially led to endodontic failure. In several VPT cases, pulp necrosis occurred which led to failure of the desired VPT. Failed cases of revascularization showed persistent inflammatory clinical signs and symptoms and increase in the size of periradicular lesion.

Patients were recalled after at least 3 months. Successful cases were defined as successful in both clinical and radiographic evaluations which is a similar recall period chosen in previously published prospective and retrospective cohort studies.[1],[4],[39],[40]

However, the study results are limited as only a small sample has been considered and factors affecting the success and failure of these treatments have not been specified. Therefore, future prospective studies need to conduct analysis on a larger sample size with longer follow-up periods for better evaluation of the healing outcomes of VPT, revascularization, and apexification.

  Conclusion Top

The outcome of VPT, revascularization, and apexification was fairly high with healing of periapical periodontitis, absence of signs and symptoms, and root maturation.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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