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Regenerative Endodontic Procedures Using Contemporary Endodontic Materials

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Regenerative Endodontic Procedures Using Contemporary Endodontic Materials materials Review Regenerative Endodontic Procedures Using Contemporary Endodontic Materials Simone Staffoli 1, Gianluca Plotino 1,* , Barbara G. Nunez Torrijos 1, Nicola M. Grande 2, Maurizio Bossù 1, Gianluca Gambarini 1 and Antonella Polimeni 1 1 Department of Oral and Maxillo-Facial Science, “Sapienza”-University of Rome, 00100 Rome, Italy; [email protected] (S.S.); [email protected] (B.G.N.T.); [email protected] (M.B.); [email protected] (G.G.); [email protected] (A.P.) 2 Department of Endodontics, Catholic University of Sacred Heart, 00100 Rome, Italy; [email protected] * Correspondence: [email protected] Received: 4 February 2019; Accepted: 13 March 2019; Published: 19 March 2019 Abstract: Calcium hydroxide apexification and Mineral Trioxide Aggregate (MTA) apexification are classical treatments for necrotic immature permanent teeth. The first tend to fail for lack of compliance given the high number of sessions needed; the second has technical difficulties such as material manipulation and overfilling. With both techniques, the root development is interrupted leaving the tooth with a fragile root structure, a poor crown-to-root ratio, periodontal breakdown, and high risk of fracture, compromising long-term prognosis of the tooth. New scientific literature has described a procedure that allows complete root development of these specific teeth. This regenerative endodontic procedure (REP) proposes the use of a combination of antimicrobials and irrigants, no canal walls instrumentation, induced apical bleeding to form a blood clot and a tight seal into the root canal to promote healing. MTA is the most used material to perform this seal, but updated guidelines advise the use of other bioactive endodontic cements that incorporate calcium and silicate in their compositions. They share most of their characteristics with MTA but claim to have fewer drawbacks with regards to manipulation and aesthetics. The purpose of the present article is to review pertinent literature and to describe the clinical procedures protocol with its variations, and their clinical application. Keywords: Immature permanent tooth; necrotic pulp; regenerative endodontics; revascularization; revitalization 1. Introduction Since the 1960s, the procedure indicated to treat immature permanent teeth with loss of vitality was apexification [1,2], a technique that aims to obtain a calcified apical barrier that permits the canal to be filled in a conventional way afterward [3], see Figure1. This technique has been demonstrated to be predictable and successful; however, some complications remain [4]. The traditional apexification technique used calcium hydroxide, Ca(OH)2, a strong base with a high pH (approximately 12), that was originally used in endodontics as a direct pulp-capping agent in 1928 [5]. Ca(OH)2 is formed by a powder that when in contact with an aqueous fluid dissociates into calcium and hydroxyl ions. This reaction induces a hard-tissue deposition and high antimicrobial activity [6]. The reaction of periapical tissues to this material is similar to that of pulp tissue [7]. It produces superficial necrosis and subjacent mineralization due to the matrix production caused by low-grade irritation from the necrosis. Calcium ions are attracted to that collagenous matrix and initiate calcification [8]. The mineralization of an apical barrier is promoted by high pH and the absence of Materials 2019, 12, 908; doi:10.3390/ma12060908 www.mdpi.com/journal/materials Materials 2019, 12, 908 2 of 28 microorganisms. Calcium hydroxide has antibacterial properties: It releases hydroxyl ions that are highlyMaterials oxidant 2019, and12, x FOR reactive PEER REVIEW and damage bacteria in different ways. The calcium ion instead,2 of can27 stimulate enzyme pyrophosphatase, facilitating repair mechanisms [9]. This procedure consists in openinghighly an oxidant access toand the reactive pulp, cleaning and damage the canal bacteria using in irrigationdifferent ways. agents The and calcium manual ion files instead, (generally can stimulate enzyme pyrophosphatase, facilitating repair mechanisms [9]. This procedure consists in slightly shorter to the apex), and applying a calcium hydroxide paste that is replaced periodically opening an access to the pulp, cleaning the canal using irrigation agents and manual files (generally to promote a faster healing response; the first replacement is advised after 4–6 weeks, then every slightly shorter to the apex), and applying a calcium hydroxide paste that is replaced periodically to 2–3 months until the operator feels a barrier when probing the apex with an endodontic file. After promote a faster healing response; the first replacement is advised after 4–6 weeks, then every 2–3 this,months it is advised until tothe wait operator another feels 3 a months barrier towhen finalize probin theg procedurethe apex with [10 an]. Afterendodontic the mineralized file. After this, barrier it completion,is advised the to tooth wait canalanother is filled3 months with to gutta-percha finalize the andprocedure sealer [10]. [9]. Unfortunately,After the mineralized this procedure barrier presentscompletion, some disadvantages, the tooth canal is such filled as with being gutta-percha a long treatment, and sealer taking [9]. Unfortunately, between 6 to this 24 procedure months to complete,presents where some the disadvantages, patient needs tosuch attend as being multiple a long times treatment, to assess taking progression between and 6 evaluateto 24 months the need to to changecomplete, the medication.where the patient The advantages needs to attend of changing multiple thetimes intra-canal to assess dressingprogression in betweenand evaluate sessions the are highneed pH to maintenance,change the medication. continuous The delivery advantages of OH of− changingions to thethe periapical intra-canal area, dressing the possibility in between of renewingsessions temporary are high cavity pH maintenance, filling avoiding continuous infiltrations, delivery and of to clinicallyOH− ions assessto the theperiapical barrier formation.area, the It alsopossibility allows one of renewing to replace temporary part of the cavity dressing filling that avoiding has been infiltrations, washed outand down to clinically the large assess apex, the to maintainbarrier patience formation. compliance, It also allows and toone ensure to replace complete part of contact the dressing between that the has calcium been washed hydroxide out anddown the apicalthe tissues. large apex, to maintain patience compliance, and to ensure complete contact between the calcium hydroxide and the apical tissues. Figure 1. (A) Pre-operative radiograph of a young necrotic upper left central incisor with periapical Figure 1. (A) Pre-operative radiograph of a young necrotic upper left central incisor with periapical lesion; (B) radiograph after two months medication with calcium hydroxide; (C) radiograph after six lesion; (B) radiograph after two months medication with calcium hydroxide; (C) radiograph after six D E monthsmonths medication medication with with calcium calcium hydroxide; hydroxide; ( ()D working) working length length determination; determination; (E) post-operative radiograph;radiograph; (F) four-years (F) four-years control control radiograph. radiograph. Not changingNot changing the intracanalthe intracanal medication medication may may lead lead to to the the same same result result but but at at a a later later time timeand and withwith a highera higher risk of risk infection of infection [10]. Another [10]. Another disadvantage disadvantage of this techniqueof this technique is the loss is the of mechanicalloss of mechanical strength whichstrength increases which the increases risk of root the fracturerisk of root [11]. fracture Several [11].in vitroSeveralstudies in vitro using studies immature using permanentimmature permanent teeth of different animals [12–15] are in agreement with clinical observations of cervical Materials 2019, 12, 908 3 of 28 Materials 2019, 12, x FOR PEER REVIEW 3 of 27 teeth of different animals [12–15] are in agreement with clinical observations of cervical fracture of calcium-hydroxide-treatedfracture of calcium-hydroxide-treated teeth that teeth have that received have minorreceived impacts minor orimpacts none [or11 none,16]. The[16,11]. flexural The strengthflexural of strength dentin is of given dentin by linksis given between by links hydroxyapatite between hydroxyapatite crystals and crystals collagen. and The collagen. alkalinity The of calciumalkalinity hydroxide of calcium affects hydroxide these links, affects weakening these links, the weakening dentin [12] the and dentin leaving [12] it and prone leaving to fracture. it prone Most to of thesefracture. studies Most haveof these found studies non-significant have found damagenon-significant when useddamage for when under used a month for under followed a month by a continuousfollowed decreaseby a continuous of mechanical decrease strength of mechanical in time. One strength study didin time. not findOne [ 17study] significant did not changesfind [17] in thesignificant resistance changes to mechanical in the resistance stress, suggesting to mechanical that it stress, was probably suggesting because that it they was usedprobably preparations because withthey calcium used hydroxidepreparations in with low concentrationscalcium hydroxide mixed in withlow concentrations additives that mixed could workwith additives as buffers that and thatcould the study work was
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