Radiographic and clinical outcomes of the treatment of immature permanent teeth by revascularization or apexification: a pilot retrospective cohort study

Abstract

Introduction: This retrospective cohort study compared clinical and radiographic outcomes of endodontic treatment performed in immature nonvital permanent teeth by apexification (calcium hydroxide or apical barrier with mineral trioxide aggregate) versus revascularization.

Methods: A comprehensive chart review was performed to obtain a cohort of previously completed cases with recalls. Clinical and radiographic data were collected for 31 treated teeth (19 revascularization and 12 apexification) with an average follow-up time of 17 months and a recall rate of 63%. Tooth survival, success rate, and adverse events were analyzed. Changes in radiographic root length, width, and area were quantified.

Results: The majority of treated teeth survived throughout the study period, with 30 of 31 (97%) teeth surviving (18/19 [95%] revascularization and 12/12 apexification). Most cases were also clinically successful, with 27 of 31 (87%) meeting criteria for success (15/19 [78%] revascularization and 12/12 apexification; nonsignificant difference). A greater incidence of adverse events was observed in the revascularization group (8/19 [42%] vs 1/12 [11%] in apexification) (risk ratio = 5.1; P = .04; 95% confidence interval, 0.719-35.48). Although more revascularization cases than apexification cases showed an increase in radiographic root area and width, the effect was not statistically significant.

Conclusions: In this study, revascularization was not superior to other apexification techniques in either clinical or radiographic outcomes. Studies with large subject cohorts and long follow-up periods are needed to evaluate outcomes of revascularization and apexification while accounting for important covariants relevant to clinical success.

Keywords: Apexification; clinical outcomes; clinical success; endodontics; maturogenesis; radiographic outcomes; radiographic root area; regenerative endodontics; revascularization.

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

Flow chart showing number of cases screened and excluded for not meeting study criteria, or for not having documentation of a recall visit.

Figure 2

Scatter plots demonstrating the percentage change in measured radiographic root dimensions. Each dot represents an individual treated tooth with closed circles from APEX cases and open squares from REVASC cases. The middle horizontal line represents the mean and the error bars are the standard deviation. The dashed horizontal line denotes a 20% increase dimension, which represents an arbitrary cut-off point to represent a potentially clinically meaningful change. A) Graph of the percentage change in radiographic root area (RRA). Three REVASC cases had 20% or greater change in RRA. B) Graph of the percentage change in length. One APEX case had a 20% increase or greater change in length. C) Graph of the percentage change in width. Three REVASC cases had 20% or greater change in width.

Figure 3

Radiographs of representative clinical cases included in this retrospective cohort study. A-C: This case involved an 8 year old male who traumatized tooth #9, causing a fracture that involved the pulp. The case was treated with calcium hydroxide APEX A: Pre-operative radiograph B: Post-operative Radiograph C: Follow up radiograph 19 months after treatment. The arrow points out the apex, to illustrate that this tooth demonstrated root lengthening after treatment as well as apical calcification. D-F: This case involved a 9 year old male with trauma to tooth #9, causing a fracture involving the pulp. The case was treated by MTA APEX. D: Pre-operative radiograph. E: Post-operative radiograph F: Follow up radiograph 10 months after treatment. G-I: This case involved a 9 year old female with intrusion trauma to teeth #8 and #9. Both teeth were treated by REVASC. G: Pre-operative radiograph. H: Post-operative radiograph. I: Follow up radiograph 12 months after treatment. Note the lack of root thickening or lengthening in tooth #8 and formation of an apical barrier in tooth #9, without obvious thickening or lengthening of the root. J-L: This case involved a 9 year old male with trauma to tooth #8. The case was treated by REVASC. J: Pre-operative radiograph. K: Post-operative radiograph. L: Follow up radiograph 23 months after treatment. Note the clear root thickening and lack of root lengthening, relative to the pre-operative image.