Management of Immature Permanent Necrotic Teeth Treated by Regenerative Endodontic: A Systematic Review

Elham Qasemian

doi:10.56101/rimj.v5i1.197

Authors

Elham Qasemian Herat University

DOI:

https://doi.org/10.56101/rimj.v5i1.197

Keywords:

Regenerative endodontic treatment, Immature necrotic teeth, Permanent teeth, Treatment outcomes, Root maturation

Abstract

Background: Regenerative endodontics is an evolving field of dentistry that focuses on biological restoration and tissue regeneration rather than traditional apexification techniques. This approach utilizes biological materials, growth factors, and scaffolds to stimulate natural healing, enabling root dentin thickening and lengthening. Regenerative endodontic procedures (REPs) aim to replace damaged structures, relieve symptoms, promote bone healing, and enhance root maturation. The success of REPs relies on three key components: stem cells, signaling molecules, and an appropriate scaffold to support cell growth and differentiation.

Methods: This systematic review evaluates the management of immature permanent necrotic teeth treated with regenerative endodontic procedures. A comprehensive literature search was conducted in PubMed and Google Scholar databases for studies published between 2015 and 2024, following PRISMA guidelines. Case series and case reports were included based on predefined eligibility criteria. Data extraction focused on patient demographics, etiology, radiographic findings, treatment protocols, and clinical outcomes.

Results: The findings indicate that regenerative endodontic treatment is highly effective, with a success rate of 82.6%, demonstrating significant healing of pre-apical radiolucency and root maturation. The most commonly used irrigation protocol involved NaOCl, saline, and EDTA, while Triple Antibiotic Paste (TAP) was the preferred intracanal medicament. MTA was the most frequently used capping material, and Platelet-Rich Fibrin (PRF) and Blood Clot (BC) were the most commonly utilized scaffolds. Despite the high success rate, a small percentage of cases were only partially successful or failed, emphasizing the need for further research to refine treatment protocols and improve long-term outcomes.

Conclusion: This review highlights the importance of regenerative endodontic techniques in promoting root development and periapical healing, offering a biologically driven approach to managing immature necrotic teeth. Further studies are required to optimize treatment strategies and enhance clinical predictability.

Author Biography

Elham Qasemian, Herat University

Endodontic and Operative Department, Stomatology Faculty, Herat University, Herat, Afghanistan

References

Ismaeal SH, Elhendawy FA, Khattab A. Evaluation of blood clot and collagen sponge in regeneration of nonvital immature permanent anterior teeth. Tanta Dental Journal. 2023;20(1):54-9.

Prakash AJ, Naik SV, Attiguppe P. Comparative Evaluation of the Regenerative Potential of Blood Clot and Platelet-rich Fibrin in Young Permanent Teeth Based on the Revised American Academy of Endodontics Clinical Considerations for Regenerative Procedure: 2016. Int J Clin Pediatr Dent. 2023;16(Suppl 2):149-54.

Markandey S, Das Adhikari H. Evaluation of blood clot, platelet-rich plasma, and platelet-rich fibrin-mediated regenerative endodontic procedures in teeth with periapical pathology: a CBCT study. Restor Dent Endod. 2022;47(4):e41.

Meschi N, EzEldeen M, Garcia AET, Lahoud P, Van Gorp G, Coucke W, et al. Regenerative endodontic procedure of immature permanent teeth with leukocyte and platelet-rich fibrin: a multicenter controlled clinical trial. Journal of Endodontics. 2021;47(11):1729-50.

Zhang Y, Sheng M. Clinical and radiographic evaluation of regenerative endodontic procedures (REPs) with or without concentrated growth factor (CGF) as scaffolds for non-vital immature mandibular premolars. The Journal of clinical pediatric dentistry. 2024;48(4):168-75.

Sobhnamayan F, Sahebi S, Moazami F, Malekzadeh P, Hasani S. Combination of metformin and double antibiotic paste for the regeneration of non-vital immature teeth: a preliminary randomized clinical study. BMC Oral Health. 2023;23(1):847.

Hargreaves KM, Giesler T, Henry M, Wang Y. Regeneration potential of the young permanent tooth: what does the future hold? Pediatric dentistry. 2008;30(3):253-60.

ElSheshtawy A, Nazzal H, El Shahawy O, El Baz A, Ismail S, Kang J, et al. The effect of platelet‐rich plasma as a scaffold in regeneration/revitalization endodontics of immature permanent teeth assessed using 2‐dimensional radiographs and cone beam computed tomography: a randomized controlled trial. International Endodontic Journal. 2020;53(7):905-21.

Ragab RA, Lattif A, Dokky N. Comparative Study between Revitalization of Necrotic Immature Permanent Anterior Teeth with and without Platelet Rich Fibrin: A Randomized Controlled Trial. The Journal of clinical pediatric dentistry. 2019;43(2):78-85.

Sabrah AH, Yassen GH, Spolnik KJ, Hara AT, Platt JA, Gregory RL. Evaluation of residual antibacterial effect of human radicular dentin treated with triple and double antibiotic pastes. Journal of endodontics. 2015;41(7):1081-4.

Ranjan M. Review on Biodentine-A Bioactive Dentin Substitute.

Arora A, Bhesania D, Kapoor S, Kaur H. A 5 years' follow-up of root anatomy-based maturogenesis achieved in infected immature molars using regenerative techniques–A case series. Journal of Conservative Dentistry and Endodontics. 2020;23(4):422-7.

Atwal PK, Malik G, Khanna S. Healing of an Immature Permanent Tooth with Large Periapical Radiolucency, Treated with Autologous Platelet-rich Fibrin Aided Regeneration. Indian Journal of Dental Sciences. 2024;16(1):43-6.

Ray Jr HL, Marcelino J, Braga R, Horwat R, Lisien M, Khaliq S. Long‐term follow up of revascularization using platelet‐rich fibrin. Dental Traumatology. 2016;32(1):80-4.

Belghuith A, Kikly A, Glii W. Regenerative endodontic of necrotic Immature Permanent Tooth using platelet-rich fibrin: A case report. J Dent Maxillofacial Res. 2023;6(3):61-5.

Bora A, Zahir S, Kundu GK, Goswami A. Regenerative pulp therapy for immature nonvital teeth with plasma-rich fibrin. SRM Journal of Research in Dental Sciences. 2015;6(3):198-202.

Çimen C, Şen S, Şenay E, Bezgin T. Platelet-rich fibrin used as a scaffold in pulp regeneration: case series. Cumhuriyet Dental Journal. 2021;24(1):113-20.

de Almeida ENM, Costa JLdSG, Júnior JLY, Ramos ATPR, Besegato JF, Júnior AJ, et al. Regenerative endodontic protocol in immature teeth: clinical case reports: Regenerative endodontic treatment. Journal of Research in Dentistry. 2023;11(3):1-6.

Gercekçioğlu S, Ekmen H, Döken T, Bayram M, Bayram E. Regenerative Endodontic Treatment of Permanent Teeth with Open Apex: Case Series. European Annals of Dental Sciences. 2022;49(1):28-33.

Handa A, Bhullar KK, Kaur S, Kaur K, Malhotra S, Kaur R, et al. Regenerative Endodontic Management of maxillary central incisor with an immature apex–A Case Report. Journal of Advanced Medical and Dental Sciences Research. 2021;9(8):118-25.

Jose SC, Mathew J, Mathews SE. Revascularization in Immature Permanent Teeth-A Case Series. Journal of Nepalese Association of Pediatric Dentistry. 2023;4(1):46-53.

Jose D, Shoba K, Babu S, Aman S. Revascularization of Necrotic Permanent Immature Teeth Using Platelet-Rich Fibrin: A Case Series.

Kandemir Demirci G, Güneri P, Çalışkan M. Regenerative endodontic therapy with platelet rich fibrin: case series. Journal of Clinical Pediatric Dentistry. 2020;44(1):15-9.

Ajram J, Khalil I, Gergi R, Zogheib C. Management of an Immature Necrotic Permanent Molar with Apical Periodontitis Treated by Regenerative Endodontic Protocol Using Calcium Hydroxide and MM-MTA: A Case Report with Two Years Follow Up. Dentistry journal. 2019;7(1).

Samsudin NA, Velloo CDS, Samsudin NI, Ghani NRNA. Revascularization medicaments of the traumatized immature permanent incisor-A case report. Journal of Biomedical and Clinical Sciences (JBCS). 2021;6(1):1-9.

Nagaveni N, Poornima P, Joshi JS, Pathak S, Nandini D. Revascularization of immature, nonvital permanent tooth using platelet-rich fibrin in children. Pediatric dentistry. 2015;37(1):1E-6E.

Orduña JFG, Caviedes-Bucheli J, Céspedes MCM, Jimeno EB, Biedma BM, Segura-Egea JJ, et al. Use of platelet-rich plasma in endodontic procedures in adults: regeneration or repair? A report of 3 cases with 5 years of follow-up. Journal of endodontics. 2017;43(8):1294-301.

Patel N, Moodley D, Peck C, Moodley T. Management of necrotic pulp of immature permanent incisor tooth: a regenerative endodontic treatment protocol: case report. South African Dental Journal. 2017;72(3):122-5.

Reena B, Patil D, Sinha A, Saoji H, Sharma D, Mali S. Endodontic management of open apex in permanent teeth using Biodentine and Platelet–rich fibrin membrane barrier as an internal matrix: A case report. 2022.

Singh M, Boruah LC, Gupta V, Bhatt A, Rajkumar B. Regeneration of Dental Pulp: The Treatment of Immature Necrotic Permanent Teeth. Journal of Advanced Medical and Dental Sciences Research. 2019;7(3):104-8.

Subash D, Shoba K, Aman S, Bharkavi SK. Revitalization of an Immature Permanent Mandibular Molar with a Necrotic Pulp Using Platelet-Rich Fibrin: A Case Report. J Clin Diagn Res. 2016;10(11):Zd21-zd3.

Tomer AK, Mangat P, Behera A, Kour S, Gupta A, Bhagat V, et al. Revascularisation of an immature permanent tooth using platelet rich fibrin and biodentin as a matrix a case report. IJMBS. 2019;3(7):2737.

Yang Y-Q, Wu B-L, Zeng J-K, Jiang C, Chen M. Pulp revascularization on an adult mandibular right second premolar: A case report. World Journal of Clinical Cases. 2022;10(17):5833.

Yadav SS. Revascularisation of non-vital immature teeth with platelet rich fibrin: A report of 2 cases. 2018.

Alasqah M, Khan SIR, Alfouzan K, Jamleh A. Regenerative Endodontic Management of an Immature Molar Using Calcium Hydroxide and Triple Antibiotic Paste: a Two‐Year Follow‐Up. Case Rep Dent. 2020;2020(1):9025847.

Aldakak MMN, Capar ID, Rekab MS, Abboud S. Single-visit pulp revascularization of a nonvital immature permanent tooth using Biodentine. Iranian endodontic journal. 2016;11(3):246.

Alencar MN, Kowaltschuk TC, Kowalczuck A, Carneiro E, da Silva Neto UX, Ditzel Westphalen VP. Regenerative Endodontic Treatment of a Traumatized Immature Necrotic Permanent Incisor: A Case Report. Iran Endod J. 2022;17(3):146-50.

Almalki MA. Regenerative Endodontic Procedure on an Immature Necrotic Molar: A Case Report with a 5-Year Review. The American Journal of Case Reports. 2024;25:e944179-1.

Asgary S. Long-Term Success of Regenerative Endodontic Treatment in Managing Traumatized Teeth: A Case Report With Seven-Year Follow-Up. Cureus. 2024;16(3):e57012.

Carmen L, Asunción M, Beatriz S, Rosa YV. Revascularization in Immature Permanent Teeth with Necrotic Pulp and Apical Pathology: Case Series. Case Rep Dent. 2017;2017:3540159.

Das S, Srivastava R, Thosar NR, Khubchandani M, Ragit R, Malviya N. Regenerative Endodontics-Reviving the Pulp the Natural Way: A Case Report. Cureus. 2023;15(3):e36587.

Faizuddin U, Solomon RV, Mattapathi J, Guniganti SS. Revitalization of traumatized immature tooth with platelet-rich fibrin. Contemp Clin Dent. 2015;6(4):574-6.

Feli M, Taheri A, Mehrabani M. Revascularization of a Previously Treated Mandibular First Molar with Open Apices: A Case Report. Iran Endod J. 2024;19(2):120-3.

Hajizadeh S, Youzbashi Zadeh R, Vatanparast N. Pulp Revascularization in Three Immature Permanent Mandibular Molars with Necrotic Pulps: A Case Series. Iran Endod J. 2019;14(4):301-5.

Hosseini S, Chitsaz N, Hamrah MH, Maleki D, Taghizadeh E. Regenerative Endodontic Management of an Immature Necrotic Premolar Using Advanced Platelet-Rich Fibrin. Case Rep Dent. 2023;2023:1135413.

Jadhav GR, Shah D, Raghvendra SS. Autologus Platelet Rich Fibrin aided Revascularization of an immature, non-vital permanent tooth with apical periodontitis: A case report. Journal of natural science, biology, and medicine. 2015;6(1):224-5.

John A, Hegde AM, Shetty P, Shetty S. Revascularization of an immature permanent central incisor with complicated crown root fracture: a case report. International Journal of Clinical Pediatric Dentistry. 2019;12(1):59.

Khoshkhounejad M, Shokouhinejad N, Pirmoazen S. Regenerative Endodontic Treatment: Report of Two Cases with Different Clinical Management and Outcomes. J Dent (Tehran). 2015;12(6):460-8.

Kumar JK, Surendranath P, Eswaramoorthy R. Regeneration of immature incisor using platelet rich fibrin: report of a novel clinical application. BMC Oral Health. 2023;23(1):69.

Lenzi R, Brisson-Suárez K, Baasch A, Alves FRF, Rôças IN, Siqueira JF, Jr. Successful regenerative endodontic treatment in a tooth with incomplete root apex and posttreatment apical periodontitis: A case report. Journal of clinical and experimental dentistry. 2022;14(6):e506-e9.

Maniglia-Ferreira C, Gurgel Filho ED, Gomes FA, Reis SA, Pappen FG. 12-Year Follow-Up of Regenerative Endodontic Treatment of Immature Permanent Upper Incisors with Acute Abscess. Braz Dent J. 2020;31(6):680-4.

Miltiadous M-EA, Floratos SG. Regenerative endodontic treatment as a retreatment option for a tooth with open apex-a case report. Brazilian Dental Journal. 2015;26:552-6.

Nagaveni NB, Pathak S, Poornima P, Joshi JS. Revascularization Induced Maturogenesis of Non-Vital Immature Permanent Tooth Using Platelet-Rich-Fibrin: A Case Report. The Journal of clinical pediatric dentistry. 2016;40(1):26-30.

Biradar N, Ragulakollu R, Tej G, Bogishetty C, Gandham S, Vardhan P. Combination Therapy of Antibiotics and Platelet-rich Fibrin for Apical Closure: Case Series. Int J Clin Pediatr Dent. 2023;16(3):541-6.

Nivedhitha MS, Jacob B, Ranganath A. Concentrated Growth Factor: A Novel Platelet Concentrate for Revascularization of Immature Permanent Teeth-A Report of Two Cases. Case Rep Dent. 2020;2020:1329145.

Pace R, Giuliani V, Di Nasso L, Pagavino G, Franceschi D, Franchi L. Regenerative Endodontic Therapy using a New Antibacterial Root Canal Cleanser in necrotic immature permanent teeth: Report of two cases treated in a single appointment. Clin Case Rep. 2021;9(4):1870-5.

Ramezani M, Sanaei-Rad P, Hajihassani N. Revascularization and vital pulp therapy in immature molars with necrotic pulp and irreversible pulpitis: A case report with two-year follow-up. Clin Case Rep. 2020;8(1):206-10.

Solomon RV, Faizuddin U, Guniganti SS, Waghray S. Analysis of the rate of maturogenesis of a traumatized Cvek's stage 3 anterior tooth treated with platelet-rich fibrin as a regenerative tool using three-dimensional cone-beam computed tomography: an original case report. Indian journal of dental research : official publication of Indian Society for Dental Research. 2015;26(1):90-5.

Van Le H, Nguyen TA, Vu TS. Regenerative Endodontic Procedures of Immature Permanent Premolars with Periapical Lesions: A Report of Two Cases Using Two Different Materials, 18-Month Follow-Up. Case Rep Dent. 2023;2023:5577474.

Yu M, Wu S, Deng S. Segmental root development of immature necrotic permanent teeth following regenerative endodontic procedures: a case series. The Journal of clinical pediatric dentistry. 2024;48(5):200-7.

Alghamdi F, Alsulaimani M. Regenerative endodontic treatment: a systematic review of successful clinical cases. Dental and Medical Problems. 2021;58(4):555-67.

Li J, Zheng L, Daraqel B, Liu J, Hu Y. Treatment outcome of regenerative endodontic procedures for necrotic immature and mature permanent teeth: a systematic review and Meta-analysis based on randomised controlled trials. Oral health & preventive dentistry. 2023;21:b4100877.

Kharchi AS, Tagiyeva-Milne N, Kanagasingam S. Regenerative endodontic procedures, disinfectants and outcomes: a systematic review. Primary dental journal. 2020;9(4):65-84.

Shaik I, Tulli M, Unnam P, Karunakaran S, Vaddi DS, Jabeen R, et al. Regenerative endodontic therapy in the management of nonvital immature permanent teeth: a systematic review and meta-analysis. Journal of Pharmacy and Bioallied Sciences. 2021;13(Suppl 1):S36-S42.

Sabeti M, Ghobrial D, Zanjir M, da Costa BR, Young Y, Azarpazhooh A. Treatment outcomes of regenerative endodontic therapy in immature permanent teeth with pulpal necrosis: A systematic review and network meta‐analysis. International Endodontic Journal. 2024;57(3):238-55.