Case Report/Clinical Techniques

Regenerative Treatment of an Immature, Traumatized

Tooth With Apical Periodontitis: Report of a Case
Elisabetta Cotti, DDS, MS, Manuela Mereu, DDS, and Daniela Lusso, DDS

Abstract
This case report describes the treatment of a necrotic
immature permanent central incisor with complete
crown fracture, suspected root fracture, and sinus tract,
T he traumatic injury of an immature permanent tooth can lead to the loss of pulp
vitality and arrested root development. The consequences of interrupted develop-
ment include a poor crown-root ratio, a root with very thin walls, an increased risk of
which was not treated with conventional apexification fracture, and an apex that is open. The traditional endodontic management of such
techniques. Instead, a regenerative approach based on cases typically includes debriding the root canal, disinfecting the space, and final ob-
the trauma literature’s methods for revascularization turation of the system preceded either by an apexification procedure or by developing
was provided. The root canal was gently debrided of an apical barrier by using materials such as mineral trioxide aggregate (MTA) (1– 4).
necrotic tissue with a sharp spoon excavator and irri- The apexification clinical procedure, which consists of applying calcium hydrox-
gated for only one third of its length with NaOCl and ide as an intracanal medication to induce an apical closure over time, has a certain
then medicated with calcium hydroxide. After 15 days predictability of success (1–3). Its disadvantages are the necessity of multiple visits
the sinus tract had healed, and the tooth was asymp- during a relatively long period of time (an average of 12 months) and the fact that there
tomatic. The tooth was accessed, calcium hydroxide is no expectation that the root canal walls will be strengthened (3, 5).
was removed, bleeding was stimulated to form an An alternative to traditional apexification is to place an artificial barrier at the apex
intracanal blood clot, and mineral trioxide aggregate to prevent the extrusion of filling materials during obturation. The material of choice is
was placed coronally to the blood clot. After 8 months, MTA for its sealing ability and its biocompatibility (4). This latest technique is conve-
a coronal calcified barrier was radiographically evident nient because it is faster than the traditional apexification. The case can be finalized
and accompanied with progressive thickening of the within 2 appointments, and a hard tissue barrier eventually forms against the MTA (4).
root wall and apical closure. Two and a half years after However, even this alternative approach has the same disadvantage of a tooth with thin
treatment was initiated, the tooth remained asymptom- dentinal walls and no further root development.
atic, and the sinus tract had not reappeared. The pro- The ideal treatment to obtain further root development and thickening of dentinal
gressive increase in the thickness of the dentinal walls
walls in an immature tooth with apical periodontitis would be to stimulate the regen-
and subsequent apical development suggest that ap-
eration of a functional pulp-dentin complex (6 – 8). This outcome has been observed
propriate biologic responses can occur with this type of
after reimplantation in avulsed immature permanent teeth (9). It has been proposed
treatment of the necrotic immature permanent tooth
that reimplantation of the tooth with an open apex permits coronal proliferation of
with sinus tract. (J Endod 2008;34:611– 616)
tissue, leading to replacement of the necrotized pulp and subsequent continued devel-
Key Words opment of the root (9). Although the histologic identity of this pulp-like tissue is
Apical periodontitis, open apex, regeneration, revascu-
generally unknown, radiographic presentation often includes progressive thickening of
larization
the dentinal walls and apical closure. Some reports, mostly published in recent years,
have shown that even the immature permanent tooth with nonvital pulp and apical
periodontitis can undergo pulp regeneration or revascularization (6 – 8). Because the
term regeneration is based on clinical and radiographic outcomes and not histologic
From the Department of Conservative Dentistry and End- or biochemically based assessments, one can only make a clinically functional inter-
odontics, School of Dentistry, University of Cagliari, Cagliari, pretation of the healing process. It is not known whether a complete pulp-dentin
Italy. complex has been regenerated. However, once the regeneration protocol is completed,
Address requests for reprints to Dr Elisabetta Cotti, Uni-
versity of Cagliari, Department of Conservative Dentistry and
these teeth can continue to develop, with the radiographic presentation of full tooth
Endodontics, Via Roma 149, 09124 Cagliari, Italy. E-mail ad- development and the clinical presentation of an asymptomatic functional tooth.
dress: cottiend@tin.it. The typical revascularization protocol advocates that the immature tooth, diag-
0099-2399/$0 - see front matter nosed with apical periodontitis (7), should be accessed and irrigated with either 5%
Copyright © 2008 by the American Association of
Endodontists.
NaOCl ⫹ 3% H2O2 (7) or 5.25% NaOCl (8) and PeridexTM (Procter & Gamble,
doi:10.1016/j.joen.2008.02.029 Cincinnati, OH) (6). An antimicrobial agent (either an antibiotic such as metronidazole ⫹
ciprofloxacin (7) or ciprofloxacin⫹ metronidazole⫹ minocycline (6) or Ca (OH)2
(8)) should be then applied into the root canal system, and the access cavity is sealed.
After an average of 3 weeks, in the absence of symptoms, the tooth is re-entered, the
tissue is irritated until bleeding is started and a blood clot produced, and then MTA is
placed over the blood clot (6), and the access is sealed. Within the next 2 years a gradual
increase in root development can be observed (6 – 8).
In the present case report, we describe the use of this protocol to stimulate the
continued root development in a case of trauma-induced necrosis and sinus tract of an
immature permanent central incisor.

JOE — Volume 34, Number 5, May 2008 Regenerative Treatment of an Immature, Traumatized Tooth With Apical Periodontitis 611
Case Report/Clinical Techniques
Case Report
A 9-year-old girl presented at the Department of Conservative Den-
tistry and Endodontics of the University of Cagliari. The patient was
accompanied by her mother, who reported that her daughter had suf-
fered a traumatic injury to the maxillary central incisors about 1 month
earlier. She did not have symptoms immediately after the accident, but
subsequently she reported losing coronal fragments from the maxillary
right central incisor. They then decided to visit a dentist. The medical
history of the girl was not remarkable. The clinical examination revealed
the fracture of most of the crown with pulp exposure in the right max-
illary central incisor. Several crown fragments remained but were
clearly fractured (Fig. 1). In addition, a sinus tract was present in the
buccal mucosa, roughly corresponding to the apical third of the root
(Fig. 2). A fracture also involved the incisal third of the crown of the left
maxillary central incisor, with a small pulp exposure. The patient was
asymptomatic, and sensitivity testing with cold elicited a negative re- Figure 2. Photograph showing the sinus tract and the crown fracture on tooth
sponse from the upper right central incisor and a positive response #8 (September 2004).
from the left central incisor. Tooth #8 was also sensitive to percussion
and palpation tests; tooth #9 was not. Radiographic examination
showed that both the roots were immature with open apices. The right The prognosis of the right central incisor appeared highly unfa-
central incisor had a small lateral apical radiolucency, and the image vorable because of the combination of the following problems: (1)
suggested the presence of a root fracture in the apical third (Fig. 1, complete fracture of the crown, (2) pulp necrosis; (3) immature root
arrows). The prognosis of the left central incisor was good, and it was with open apex, and (4) the radiographic appearance of a fracture of
decided to perform a shallow pulpectomy with a permanent restoration. the apical third of the root (in the area where the sinus tract was traced).
It was decided that attempting to perform an apexification (and there-
fore instrumenting the root to length) would seriously compromise the
structural integrity of the tooth, possibly leading to a split tooth. It was
then decided to attempt a pulp regeneration procedure.
The mother was informed that the treatment of the right central
incisor (#8) would be an attempt to extend the life of the root, and that
this treatment might not be effective either in the short-term or in the
long-term. A special informed consent was therefore signed. Under
local anesthesia and rubber dam isolation, the left maxillary central
incisor pulp horn was disinfected by using a cotton pellet saturated with
5.25% NaOCl, and a very shallow pulpectomy was done, with applica-
tion of Ca(OH)2 powder followed by a drop of light-cured glass ionomer
cement. The tooth was restored with temporary cement and subse-
quently restored with a bonded composite resin. Then the residual
coronal fragments were removed from the right maxillary central inci-
sor, and the access cavity was prepared (Figs. 2 and 3). The pulp tissue
was removed mechanically for approximately 1/3 of the root length by
using a small and very sharp spoon excavator. The tissue did not appear
to be vital, and no bleeding could be observed. The coronal part of the
canal was then irrigated with 5.25% NaOCl alternated to 3% H2O2; it was
dried with a cotton pellet, and a Ca(OH)2 powder medication was
placed in contact with the soft tissue in the root canal by using a #10
Schilder’s plugger. The access cavity was sealed with a cotton pellet and
a provisional restoration (Cavit; ESPE, Chergy Pontoise, France).
The patient was seen the next week, and she was asymptomatic.
One week later, the patient returned to the clinic for the third appoint-
ment. Both teeth were asymptomatic, not sensitive to percussion or
palpation, and the sinus tract had disappeared (Fig. 4). Tooth #8 did not
respond to cold sensitivity test. Tooth #8 was then isolated with the
rubber dam and reaccessed. Calcium hydroxide was removed by irri-
gation with 5.25% NaOCl, and after drying of the space, bleeding and the
formation of a blood clot were stimulated. Then MTA (Pro-Root MTA;
Dentsply Maillefer, Baillagues, Switzerland) was condensed for approx-
imately 3 mm by using a Schilder’s plugger and an ultrasonic tip for 10
seconds; it was covered with a moist cotton pellet, and the access was
Figure 1. Detail from the panoramic radiograph showing tooth #8 with the sealed with Cavit.
crown fractures, the root fracture, and the open apex (arrows) (September When the patient returned 1 week later for her fourth appoint-
2004). ment, a glass ionomer sealer was placed against the MTA cement, and

612 Cotti et al. JOE — Volume 34, Number 5, May 2008

 Case Report/Clinical Techniques

Figure 3. Periapical radiograph showing tooth #8 after the removal of the frag-
ments of the fractured crown (September 2004).

Figure 5. Radiograph showing tooth #8 after blood clot formation, positioning

the tooth was restored with an adhesive composite resin. The crown was of MTA and glass ionomer cement and composite resin (September 2004).
not completely restored in its anatomy as a result of a lack of retention
and the desire to minimize masticatory forces applied to the tooth. It was
explained to both the mother and the young girl that this would be the graphic presence of a hard tissue bridge under the MTA in the coronal
best option to allow the root to undergo further development (Fig. 5). portion of the root. The cold sensitivity, percussion, and palpation tests
At the recall appointments (3, 6, 12, 18, 24, and 30 months), the were performed at each visit, but the response of the maxillary right
patient was always asymptomatic, the sinus tract over the right central central incisor was always negative. At this time, a better composite
incisor did not reappear, and the radiographic presentation of the root coronal restoration was placed on the tooth by using dentin pins. The
fracture healed. The intraoral radiographs taken at each evaluation tooth has remained functional with continued root development includ-
showed a good condition of the periapical tissues, with the continued ing increased dentinal wall thickness (Figs. 6 – 8).
development and closure of the root apex.
After 8 months from the beginning of treatment, it was clear that Discussion
the situation was stabilized. It was also possible to observe the radio- The traditional approach for treating this case of a necrotic imma-
ture permanent tooth with sinus tract would have been either apexifi-
cation with calcium hydroxide medication or apexification with MTA
(3, 4). However, the apexification treatment does not lead to a further
thickening of dentinal walls or an increased root length. Moreover,
complete instrumentation of the root canal system would have pre-
vented any possible repair of a horizontal fracture (1, 3). A more con-
servative approach for this type of case would be to perform a regener-
ative procedure by not instrumenting the root canal and instead using
only copious irrigation and the application of antimicrobial agents to
preserve any remaining vital pulp tissue in the apical region. The out-
come of the conservative treatment depends on the type and duration of
the infection, the state of the pulp at the time treatment is started, the
host, and the size of the open apex (8, 9).
The chance for revascularization of a reimplanted tooth increases
by 18% if the apex is open ⬎1.1 mm, and the tooth is reimplanted
within 45 minutes (9). Iwaya et al (7) reported a case of an immature
tooth with an open apex, periapical radiolucency, and sinus tract that
Figure 4. Buccal view of tooth #8 after removal of all fractured fragments and responded with gradual root development during a 30-month follow-up
healing of the sinus tract (September 2004). period. In that case, the root canal was not mechanically cleaned to its

JOE — Volume 34, Number 5, May 2008 Regenerative Treatment of an Immature, Traumatized Tooth With Apical Periodontitis 613
Case Report/Clinical Techniques

Figure 6. Intraoral radiographs showing the response of the tooth to treatment with respect to the original status: progressive development of the root (A, marked);
the formation of the coronal barrier and the narrowing of the apical area (B, arrows); the apical closure (C, circled).

full length because of the patient’s sensitivity reaction to the insertion of to permit the drainage of blood and purulent exudate. During the sec-
a small broach. This observation suggested that some residual vital pulp ond to the fifth weekly visits, the canal was irrigated with 5% NaOCl and
tissue remained within the canal. In the first visit, the tooth was left open 3% H2O2, without any instrumentation. Metronidazole and ciprofloxa-

614 Cotti et al. JOE — Volume 34, Number 5, May 2008

 Case Report/Clinical Techniques
Chueh and Huang (8) recently reported 4 clinical cases of imma-
ture teeth with periradicular periodontitis or abscess. The teeth were
treated without instrumentation; instead, they were treated by irrigation
with 2.5% sodium hypochlorite and application of Ca(OH)2 paste med-
ication. All 4 cases developed mature apices with increased root length
and dentinal wall thickness after 7 months–5 years.
In the present case report the treatment choice was dictated by the
many different problems present in the involved tooth. The crown was
nonexistent, the sinus tract corresponded to the apical area where a
root fracture was suspected, the root was short, and the apex was open.
Traditional endodontic techniques including root canal instrumenta-
tion were not considered practical under these conditions. Calcium
hydroxide was the medication of choice because of its known properties
(1, 3) and because no other medication was available at that particular
time in the Department because a revascularization protocol was not yet
established. To obtain the best conditions within the endodontic system,
copious irrigation of NaOCl (5.25%) and H2O2 (3%) was applied to
maximize the chances for disinfection of the exposed root canal surface
Figure 7. Photograph showing tooth #8 with composite restoration at 24-month followed by application of Ca(OH)2 and subsequent placement of MTA
recall.
(10) once the sinus tract healed. This conservative treatment has re-
sulted in the healing of the sinus tract and radiographic resolution of the
cin paste were used as an intracanal medication. At the fifth visit vital possible root fracture, continued thickening of the root wall, and sub-
tissue was observed 5 mm apical to the root canal orifice. At the sixth sequent apical closure and formation of a coronal dentinal bridge.
visit, calcium hydroxide was placed in contact of the pulp, and the Although these outcomes provide initial measures of successful healing,
access cavity was sealed with glass ionomer cement and adhesive com- it should be appreciated that the apex has not developed in the same way
posite resin. Fifteen months later, the canal was reopened, and with an as the contralateral incisor (Fig. 6C).
explorer it was possible to percuss a hard tissue bridge at the level of the The outcome of all these cases reported so far might have different
orifice. Radiographic examination revealed progressive apical closure possible explanations. The pulp was necrotic, and the therapy has pro-
and an increase of the thickness of the canal walls. Thirty months after duced a regeneration of a functional pulp-dentin complex; the thicken-
the initial treatment, there was a complete closure of the apex and a ing of the root canal walls and the closure of the apical foramen could
thickening of the root walls, with a reduction of the pulp space. be achieved by periodontal ligament tissue that grew into the canal and
Banchs and Trope (6) applied a similar treatment in a case of deposited cementum into the inner surface of the root dentin (8, 11); or
immature tooth with open apex and sinus tract by applying a mixture of the pulp was partially necrotic, and the treatment simply produced a
ciprofloxacin, metronidazole, and minocycline into the root canal sys- deep pulpotomy with subsequent root development as a result of a
tem with a Lentulo spiral. At the next visit 26 days later, an endodontic healthy pulp-dentin complex (12).
explorer was used to irritate the tissue at 15-mm depth to create bleed- In the first hypothesis, the outcome can be explained with survived
ing inside the canal. Then MTA was placed over the blood clot, and the pulp tissue, even in the presence of apical periodontitis and sinus tract,
tooth was restored. At 2-year follow-up there was closure of the apex probably because of the rich blood supply through the wide open apex.
and thickening of the dentinal walls. Interestingly, the tooth responded It has been observed that in mature teeth there might be still remaining
positively to the cold test. vital pulp tissue even when a periradicular lesion is developed (13). In

Figure 8. Sequence of radiographic details showing the progressive root strengthening, coronal barrier, and apical formation in tooth #8 within 30 months from the
first appointment.

JOE — Volume 34, Number 5, May 2008 Regenerative Treatment of an Immature, Traumatized Tooth With Apical Periodontitis 615
Case Report/Clinical Techniques
addition, dental pulp of permanent teeth contains a population of stem endodontic treatment procedures in clinical conditions of the necrotic
cells that might provide a source of newly differentiated odontoblasts immature permanent tooth.
(14, 15). In the case of an immature tooth, stem cells have been recently The potential great advantage of providing a biologically based
described in the apical papilla that possess the ability to proliferate and procedure that permits continued root development should be bal-
form odontoblast-like cells (15). The apical papilla is a very specific anced with an informed knowledge of relative advantages and potential
stem cell tissue formation that is located apically to the differentiated risks.
pulp tissue of the developing tooth, and these stem cells are called stem
cells from the apical papilla (SCAP). The apical papilla has the potential
of remaining undamaged because it is loosely connected to the dental References
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and continue the root maturation (15). The presence of the blood clot 28:669 –97.
2. Kerekes K, Heide S, Jacobsen I. Follow-up examination of endodontic treatment in
might help the situation by acting as a scaffold (14). traumatized juvenile incisors. J Endod 1980;6:744 – 8.
In the second hypothesis, the radiographic appearance of in- 3. Rafter M. Apexification: a review. Dent Traumatol 2005;21:1– 8.
creased root thickness might be due to the ingrowth of hard tissue 4. Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral
(cementum, bone) (8, 11, 16). This outcome could not be considered trioxide aggregate. Pract Periodont Aesthet Dent 2000;12:315–20.
a regenerative reaction of the pulp-dentin complex. 5. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal
dressing may increase risk of root fracture. Dent Traumatol 2002;18:134 –7.
In the third hypothesis, the root development is simply the conse- 6. Banchs F, Trope M. Revascularization of immature permanent teeth with apical
quence of a very deep pulpotomy, and this would require us to carefully periodontitis: new treatment protocol? J Endod 2004;30:196 –200.
reconsider our ability to make a differential diagnosis between a vital, a 7. Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth
partially vital, and a nonvital pulp. with apical periodontitis and sinus tract. Dent Traumatol 2001;17:185–7.
8. Chueh L-H, Huang G T-J. Immature teeth with periradicular periodontitis or abscess
If the first hypothesis is correct, then it would appear that if we undergoing apexogenesis: a paradigm shift. J Endod 2006;32:1205–13.
provide a favorable disinfecting condition within the root canal system 9. Kling M, Cvek M, Mejàre I. Rate and predictability of pulp revascularization in 10
of immature teeth with apical periodontitis, then it is possible to obtain therapeutically reimplanted permanent incisors. Endod Dent Traumatol 1986;
regeneration of a functional pulp-dentin complex. Because most treat- 2:83–9.
ments used and described so far in successful revascularization cases 10. Sarkar NK, Caicedo R, Ritwik P, Moiseyava R, Kawashima I. Physicochemical basis of
the biologic properties of mineral trioxide aggregate. J Endod 2005;31:97–100.
are different from each other (6 – 8), it is clear that there is some 11. Seo BM, Miura M, Gronthos S, et al. Investigation of multipotent postnatal stem cells
urgency to establish the most predictable protocol to treat these teeth. from human periodontal ligament. Lancet 2004;364:149 –55.
On the other hand, if we consider that the third hypothesis might be true, 12. Cvek M. Treatment of non-vital permanent incisors with calcium hydroxide: fol-
then we have to face the everlasting problem of making the correct low-up of periapical repair and apical closure of immature roots. Odontol Rev
1972;23:27– 44.
diagnosis. There is a strong possibility that the response of the tooth to 13. Lin L, Shovlin F, Skribner J, Langeland K. Pulp biopsies from the teeth associated with
treatment in the present report would be indicative of an apexogenesis, periapical radiolucency. J Endod 1984;10:436 – 48.
but because the signs and symptoms were clearly referred to a necrotic 14. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative endodontics: a review of
pulp and periradicular pathosis, the possibility of a regeneration com- current status and a call for action. J Endod 2007;33:377–90.
ing from residual embryonic tissue at the apex is still to be considered. 15. Sonoyama W, Liu Y, Yamaza T, et al. Characterization of the apical papilla and its
residing stem cells from human immature permanent teeth: a pilot study. J Endod
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conventional endodontic treatment procedures versus regenerative permanent tooth: what does the future hold? J Endod 2008 (in press).

616 Cotti et al. JOE — Volume 34, Number 5, May 2008