Clinical and radiographic outcomes of traumatized immature permanent necrotic teeth after revascularization/revitalization therapy

Abstract

Introduction: Revascularization treatment is rapidly becoming an accepted treatment alternative for the management of endodontic pathology in immature permanent teeth with necrotic dental pulps. However, the success and timing of clinical resolution of symptoms, and radiographic outcomes of interest, such as continued hard tissue deposition within the root, are largely unknown.

Methods: In this prospective cohort study, 20 teeth were treated with a standardized revascularization treatment protocol and monitored for clinical and radiographic changes for 1 year. Standardized radiographs were collected at regular intervals, and radiographic changes were quantified.

Results: All 20 treated teeth survived during the 12-month follow-up period, and all 20 also met the clinical criteria for success at 12 months. As a group, the treated teeth showed a statistically significant increase in radiographic root width and length and a decrease in apical diameter, although the changes in many cases were quite small (such that the clinical significance is unclear). The within-case percent change in apical diameter after 3 months was 16% and had increased to 79% by 12 months, with 55% (11/20) showing complete apical closure. The within-case percent change in root length averaged less than 1% at 3 months and increased to 5% at 12 months. The within-case percent change in root thickness averaged 3% at 3 months and 21% at 12 months.

Conclusions: Although clinical success was highly predictable with this procedure, clinically meaningful radiographic root thickening and lengthening are less predictable after 1-year of follow-up. Apical closure is the most consistent radiographic finding.

Keywords: Clinical outcomes; clinical research; endodontic outcomes; prospective cohort study; radiographic outcomes; regenerative endodontics; revascularization; revitalization.

Conflict of interest statement

The authors deny any conflict of interest.

Copyright © 2014 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Radiographic findings regarding the proportion of subjects with periapical radiolucencies and open apices at various time points of the study. A) The proportion of subjects with a periapical radiolucency decreased throughout the study period and became significantly different from baseline after 9 months (McNemar’s chi2 test, 6 months: p= 0.06; 9 and 12 month: p<0.0001). B) The proportion of subjects with an open apex began to decrease after 6 months, and became significantly different from baseline at 9 months (McNemar’s chi2 test, 9 months p<0.05; 12 months p<0.001).

Figure 2

Radiographic changes in apical diameter, root length, and root width over the study period. A) Box and whiskers plot of apical diameter (mm) measured at 3 month intervals. The band inside the box represents the median. The lower chamber of the box contains the 1st quartile and the upper chamber of the box contains the 3rd quartile. The upper and lower boundaries of the whiskers represent the minimum and maximum values of the population. The change was highly significant when analyzed using repeated measures ANOVA. B) Scatter plot of the calculated percent change from baseline in apical diameter for each case measured at each follow up visit. The error bars represent the mean +/− SEM. The horizontal line represents an arbitrary cutoff of 20% change representing a clinically significant finding. C) Box and whiskers plot of root length (mm) measured at 3 month intervals. The change was highly significant when analyzed using repeated measures ANOVA. D) Scatter plot of the calculated percent change from baseline in root length for each case measured at each follow up visit. E) Box and whisker plot of the width of root wall (mm) measured at 3 month intervals. The change was highly significant when analyzed using repeated measures ANOVA. F) Scatter plot of the calculated percent change from baseline in root width for each case measured at each follow up visit.

Fig 3

An immature, fratured #8 with open apex and large periradicular radiolucency in a 11 year old boy. Periapical radiographs included showing showing: (a) Periapical radiolucent lesion with open apex. (b) Following the placement of MTA (c) At 3 months follow-up, partial regression of periapical radiolucent lesion and partial closure of the root end (d) At 6 months follow-up, with marked reduction in periapical lesion with contiuned development of the root (e) At 9 months follow-up, nearly complete healing of periapical lesion with contiuned development of the root apex (f) At one year follow-up, complete maturation of the root apex with hard tissue bridge formation noted mid root.

Fig 4

Fig.4A: A 12 year old boy presented with labial swelling and cervical pus discharge over #9. Intra-oral periapical radiograph showing: (a) Immature root with thin dentinal root walls associated with large periapical pathology. (b) Following the placement of MTA (c) At 3 months follow-up, regression of periapical radiolucent lesion and hard tissue formation at the apex; minimal thickening and lengthening of the root noted. (d) At 6 month's follow-up, with marked reduction in periapical lesion with some root thickening (e) At 9 month's follow-up, nearly complete healing of periapical lesion with continued development of the root apex. (f) At one year follow-up, mid-root calcific bridge formation noted. Fig: 4 B: Clinical photographs showing: (a) Pre-operative clinical photograph illustrates labial swelling and cervical pus discharge over #9. (b) Three-week post-operative photograph demonstrates complete healing of the swelling. (c) At 3 moth's follow-up, normal gingival contour was observed. Significant coronal staining, likely from the triple antibiotic paste was also noted. This was observed in many of the cases. (d&e) At one year follow-up with final treatment with composite resin veneer.

Fig 4

Fig.4A: A 12 year old boy presented with labial swelling and cervical pus discharge over #9. Intra-oral periapical radiograph showing: (a) Immature root with thin dentinal root walls associated with large periapical pathology. (b) Following the placement of MTA (c) At 3 months follow-up, regression of periapical radiolucent lesion and hard tissue formation at the apex; minimal thickening and lengthening of the root noted. (d) At 6 month's follow-up, with marked reduction in periapical lesion with some root thickening (e) At 9 month's follow-up, nearly complete healing of periapical lesion with continued development of the root apex. (f) At one year follow-up, mid-root calcific bridge formation noted. Fig: 4 B: Clinical photographs showing: (a) Pre-operative clinical photograph illustrates labial swelling and cervical pus discharge over #9. (b) Three-week post-operative photograph demonstrates complete healing of the swelling. (c) At 3 moth's follow-up, normal gingival contour was observed. Significant coronal staining, likely from the triple antibiotic paste was also noted. This was observed in many of the cases. (d&e) At one year follow-up with final treatment with composite resin veneer.