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Regenerative Endodontics190
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is determined visually or radiographically, and the canal is disinfected with sodium hypochlorite
(NaOCl) just before the apical foramen. A concentration of 1.5–3% is recommended for disinfection and removal of the residual tissue while sparing the local cells (23, 24). The canal is then
rinsed with 0.9% normal saline and 17% EDTA to neutralize the cytotoxic NaOCl(27). Subsequently,
excel liquid is removed with paper points and the canal is filled with a calcium hydroxide preparation or triple antibiotic paste (TAP: metronidazole, ciprofloxacin and minocycline) and adhesively
sealed until the second appointment(23, 24).
After 2–4weeks, the clinical situation is assessed and, if the tooth is asymptomatic, revitalization
may be performed (Figure9.6). After local anaesthesia, the tooth is isolated again with dental dam
and intracanal medication is removed by rinsing with 17% EDTA. This agent has several effects,
and it exposes collagen fibres as well as bioactive proteins on the dentine surface(28). After another
rinse with saline, the root canal is dried and bleeding is induced by irritation of periapical tissues
with an endodontic file, e.g. a preapproximately 2
mm below the cemento- enamel junction and be left to coagulate (Figure9.6). The
bent ISO 30 Hedström file (Figure9.7a). The blood should reach
coagulum is then covered with a collagen matrix for stabilization, followed by application of an
HCSC in direct contact (Figure 9.7b). At this point, a radiographic control is indicated and the
tooth is sealed with an adhesive restoration(23, 24).
When selecting bioactive materials to cover the collagen matrix, they should not contain additives that cause crown discolouration, e.g. barium sulphate, which is often added to MTA as a
radiopacifier. Synthetic HCSCs are particularly suitable for this purpose as they may not contain
(f) (g) (h)
Figure9.6 (a) The young patient suffered an avulsion of tooth 11, which was replanted, and subluxation
of tooth 21, which was diagnosed with necrosis during recall. (b) The root canal was accessed and
disinfected. (c) In the second session, the intracanal dressing was removed, the canal was finally rinsed with
17% EDTA and saline, and dried. (d) By over- instrumenting with a file, bleeding was induced into the canal.
(e) The blood clot was covered with a collagen matrix and (f) covered with a hydraulic calcium silicate
cement (Biodentine, Septodont, Niederkassel, Germany). (g) A radiograph was taken to verify this step.
(h)The control radiograph after six months showed no pathological findings.
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Revitalization 191
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Figure9.7 (a) A Hedström file may be bent at the tip to cause bleeding when rotated carefully in the
periapical tissue. (b) Different collagen preparations for covering the blood clot: PARASORB HD Cone (left;
RESORBA Medical, Nuremberg, Germany), Hémocollagène (centre; Septodont, Niederkassel, Germany) and
RCP Resorbable Collagen Plug (right; ACE Surgical Supply Company, Brockton, USA).
these additives and also have advantages in terms of workability and mechanical properties (e.g.
Biodentine, Septodont, Niederkassel, Germany).
To avoid problems with patient compliance, care should be taken to ensure adequate anaesthesia
and a positive treatment atmosphere(24, 29). However, it should be noted that the induction of
bleeding into the root canal is often slow in clinical practice and may be compromised by the
use of a local anaesthetic containing a vasoconstrictor. Accordingly, it is important to use a
local anaesthetic without additional vasoconstrictors to create optimal conditions for the induction
of bleeding into the canal. Furthermore, intracanal medications, especially calcium hydroxide,
should not be left in place for too long, as this may induce the formation of an calcified barrier and
thus alter the conditions for bleeding and revitalization.
Follow-Up
Follow- up visits are recommended after 6, 12, 18 and 24months and then annually for five years.
An additional visit after only three months is particularly useful in cases where the revitalization
was preceded by persistent signs of infection, resorptive processes or other risk factors such as
reimplantation or transplantation after dental trauma. All clinical and radiological parameters
should be reviewed and included in the assessment of treatment outcome.
If, as is often the case, further orthodontic therapy is necessary, it should be borne in mind that
revitalized teeth are more susceptible to inflammation and resorptive processes if the aetiology of
pulp necrosis was a traumatic dental injury (30, 31). Therefore, in the case of revitalized teeth,
bony healing should be observed before tooth movement is started and shorter follow- up intervals
should be chosen. If this cannot be guaranteed, revitalized teeth should be excluded from orthodontic movement.
OutcomeMeasures
Determining the success of a revitalization treatment is a major challenge, especially in young
patients, for a number of reasons. The results are often inconclusive due to low patient compliance, poor reliability of sensitivity testing and the almost impossible standardization of twodimensional radiographs in children and adolescents.
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Of critical importance is the distinction between different clinical and radiological outcome
parameters(22), as the terms ‘success’ and ‘failure’ may not be sufficiently precise with regard to
revitalization. Accordingly, it is reasonable to discuss whether a case is a success if a periapical
lesion is reduced in size, but there is no mineralized tissue formed within the root canal and thus,
no increase in root length and thickness is evident.
For this reason, it is important for clinicians to establish specific success criteria for revitalization. A practical and patient-
centred way to describe success is by the absence of pain, swelling and
sinus tract (primary goal) and by a response to pulp vitality tests (tertiary goal). Radiological success is defined as the reduction of apical radiolucencies (primary goal) as a result of treatment and
the progression of root growth in length and thickness (secondary goal). A clear failure is the failure to achieve the primary goal clinically or radiographically(32).
A comprehensive core outcome set as a checklist for standardized diagnosis and determination
of success or failure in clinical practice may include the following aspects(24, 33):
● clinical signs and symptoms of inflammation (e.g. pain, tenderness to percussion, swelling,
sinus tract)
● periodontal probing depths and mobility
● tooth discolouration
● response to sensitivity tests (electric, thermal)
● healing of periapical lesion
● root thickening and lengthening
ClinicalOutcome
In recent years, a large number of prospective and retrospective clinical studies have been published demonstrating the clinical success of revitalization(21, 34). Due to the initially high survival
rates, healing of periapical inflammation and increased growth in immature roots, it has been
postulated as an alternative therapy to the apical barrier technique with HCSCs(23, 24).
Despite the growing body of evidence, there is currently a lack of long- term observations, which
are essential for a comprehensive assessment of potential complications (21, 35). Although the
high survival rate of revitalized teeth motivates the use of the procedure, it must be said that the
predictability of the outcome of individual cases in terms of root growth (secondary goal) and restoration of tooth sensitivity (tertiary goal) is poor(34). Considering the available treatment alternatives for immature teeth, there is no significant difference between apexification, apical plug and
revitalization in terms of periapical healing and tooth survival(35–38).
Of the many factors that can influence the clinical success of revitalization, root canal infection
is considered to be one of the most important. Persistent bacteria are a major cause of treatment
failure, as shown by animal studies(39) and a systematic review of failed cases(31). The presence
of an apical lesion due to root canal infection can therefore be considered an important prognostic
factor. However, incomplete elimination of bacteria in the root canal is not only responsible for
failure but may also be responsible for the qualitative outcome of supposedly successful treatments(39, 40). Animal studies have shown that persisting bacteria are clearly associated with
reduced or absent hard tissue apposition in the root canal, even in the absence of radiographically
visible periapical lesions (39). In fact, a systematic review of existing controlled clinical trials
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Revitalization 193
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showed that the evidence for revitalization as a treatment for apical periodontitis is limited and
that more high-
In addition to root canal infection, the aetiology of pulp necrosis may also play a role in the success of revitalization. For example, the traumatic impact can damage Hertwig’s epithelial root
sheath (HERS) and the apical papilla, both structures essential for root growth(41). Especially
luxation injuries such as intrusive luxations severely damage the periodontium (42). When the
cause of pulp necrosis is caries or infection due to a developmental abnormality, e.g. dens evaginatus, the outcome appears to be different from those following dental trauma(21, 31, 36).
quality studies are needed(35).
RevitalizationofMatureTeeth
The basic indication for revitalization, according to the recommendations of endodontic societies,
is the treatment of immature permanent teeth with pulp necrosis(23, 24). Since then, however,
there has been increasing interest in applying this regenerative endodontic protocol to mature
permanent teeth(43, 44). At the present time, these approaches must be considered experimental,
as there are only a few studies, and the long- term prognosis of these teeth is unknown(45, 46).
When permanent teeth with mature roots are treated by revitalization, there is currently no evidence of an advantage over established conventional endodontic treatment. Even in teeth with an
open apex at an older age, it is biologically unlikely that further root development will occur, as the
supply of mesenchymal stem cells decreases with age and HERS degrades. Whereas revitalization
of mature teeth may be promising in terms of periapical healing and reto sensibility testing, clinical studies are needed to assess the clinical relevance of regenerative
endodontic procedures in permanent teeth.
establishment of a response
Biological Result
The vision of revitalization was originally to regenerate the dentine–pulp complex(9, 47). Over
time, the blood clot that has formed inside the root canal is transformed into a vascularized and
innervated tissue that exerts at least part of the functions of the original pulp(22, 25). Thus, revitalized teeth may develop sensitivity to cold, periapical inflammation may subside and root development may progress(48, 49).
Histologically, however, this tissue may be different from the original pulp. Typically, the structured odontoblast layer is absent and ectopic components such as cementum or bone can be
found(50–52). Accordingly, the biological outcome of revitalization does not represent pulp regeneration but must be considered a classic tissue repair in the biological sense (Figure9.8)(9). The
nomenclature of regenerative endodontics takes this into account, with Diogenes etal. introducing
the term ‘guided endodontic repair’(53).
Despite the biological limitations, the clinical results of revitalization are promising, and the
procedure already represents an important component of clinical endodontic practice. However,
due to dissatisfaction with the histological results and the low predictability of outcome, researchers have made great efforts to develop new procedures based on tissue engineering and regenerative medicine strategies to achieve cellular regeneration and biologically restore the dentine–pulp
complex in a reproducible manner.
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Regenerative Endodontics194
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(e)(d)
Figure9.8 (a) Control radiograph after revitalization treatment of teeth 11 and 21, which had pulpal
necrosis due to avulsion. (b) Unfortunately, external cervical resorption was noted in tooth 11 after
24months and the tooth was removed. (c) Sagittal sections after micro- CT- imaging show the new hard
tissue on root canal walls and the newly developed root apex. (d) Histological view of the whole tooth
shows connective tissue within the canal and hard tissue on the canal walls, which appears structurally
different from normal dentine. (e) The magnified view shows that the newly formed tissue does not have a
tubular structure and no odontoblast layer has developed (H&E staining; scale bars: 1 mm in c and d;
100 μm in e).
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Endodontic Tissue Engineering 195
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EndodonticTissueEngineering
Classification
The translational field of regenerative medicine encompasses diverse topics such as gene therapy,
stem cell transplantation, the use of soluble molecules, cell reprogramming and tissue engineering(54). However, tissue engineering can be seen as a distinct direction based on the use of stem
cells, scaffold materials and signalling molecules to restore tissues (55). Looking at the field of
regenerative endodontics and the application of tissue engineering in the root canal, several endodontic tissue engineering (ETE) approaches are conceivable.
In principle, a technical subdivision can be made between cellprimarily cell-
free methods (CF- ETE)(9, 56). Characteristic of cell- based methods is that specific
cells are processed exvivo and introduced into the root canal encapsulated in customized scaffolds
with added growth factors (Figure9.9a). Despite the fact that initial clinical studies show promising results(57–59), the practical implementation of cell transplantation is associated with considerable challenges and costs, and its use in everyday practice does not currently seem realistic. The
cells needed must first be harvested from donor tissue or prelaboratory and transferred back into the patient under strict regulatory conditions(60). In contrast,
the primarily cell-
free idea is based on the principle of cell homing (Figure9.9b). Endogenous stem
or progenitor cells that are locally available at the root tip are used as the cell source, thus avoiding
exvivo cell manipulation(9, 61). Another advantage of CF- ETE approaches is that they are painless unless blood products are used and easy to administer by injection into the root canal.
Following this approach, only scaffold materials are injected into the root canal together with signalling molecules, so that cells from the periapical tissue are attracted and migrate into the root
canal(61, 62). In addition, blood vessels and nerve fibres invade the canal lumen, setting the stage
for new tissue formation.
In principle, the central goal of ETE is to overcome the limits of repair and enable reproducible
pulp regeneration. At present, although preclinical and experimental studies report promising
results(58, 63, 64), sufficient evidence of biological pulp regeneration in clinical studies is seen
controversial(52, 65).
based approaches (CB- ETE) and
stored in a cell bank, expanded in the
Figure9.9 (a) Cell- based endodontic tissue
engineering involves the expansion of cells
and transplantation into the root canal together
with a scaffold and signalling molecules. (b) Cell
homing, on the other hand, is a primarily cell- free
approach that utilizes locally available cell sources.
A customized scaffold containing signalling
molecules is placed inside the canal, and cells can
migrate from the periapical tissue.
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AutologousPlateletProducts
During revitalization treatment, the blood clot formed by retrograde bleeding into the root canal
serves as a threeplatelet products such as plateletplateletfrom an orthograde direction. Here, the fibrin matrix forms a threetains blood components as well as platelets, which, according to the CFopportunity for cells to colonize the root canal. Autologous platelet products appear to improve
bone healing and support root growth in clinical studies, however, there is currently a lack of goodquality trials in this field (65–67). It should be noted that the use of blood products involves
venepuncture, which is particularly unsettling for young patients. Despite promising clinical outcomes(68–71), platelet- based techniques are, in analogy to revitalization, also emerging as biological repair rather than regeneration(56).
rich plasma (PRP) can also be introduced into the root canal through the access cavity
dimensional matrix for new tissue formation. On the other hand, autologous
rich fibrin (PRF), plasma rich in growth factors (PRGF) or
dimensional scaffold and con-
ETE concept, provide the
Conclusion
Regenerative endodontics is an exciting field that seeks to regenerate dental pulp and promote root
development. Although the conventional apical barrier technique with HCSCs has shown promise, revitalization is a viable option for immature teeth with necrotic pulp, allowing root maturation and restoration of sensibility. However, longits potential and possible complications.
At the same time, researchers are exploring new approaches to achieve cellular regeneration and
restore the dentine–pulp complex. Although cellimplementation is challenging and expensive. On the other hand, primarily cellbased on cellin the root canal. Despite encouraging preclinical and experimental results, clinical evidence for
biological pulp regeneration is lacking. Nevertheless, endodontic tissue engineering and other
regenerative approaches have the potential to overcome the limitations of repair and enable reproducible pulp regeneration, offering exciting possibilities for the future of endodontics.
homing principles have shown to be effective in supporting new tissue formation
term observations are needed to fully understand
based methods are promising, their practical
free methods
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