Traditionally, when an immature tooth became necrotic, root development was arrested and the endodontic goal was to create some kind of calcific barrier against which we could obturate. This is known as Ca(OH)2 apexification. The downside to this treatment was length of treatment time and weak, short, thin roots that remained.
More recently, MTA apexification has become more common. This consists of debridement of the immature root and immediate obturation with MTA. This shortened the treatment time, but the problem of short, thin roots still remained.
Multiple case reports, including cases at Superstition Springs Endodontics, have shown the ability to remove the necrotic tissue and stimulate regeneration of pulpal-like tissue into the canal. This allows for the continued growth of the immature root. The dentinal walls thicken, the length of root increases, periapical lesions heal and the open apex closes.
This is a completely new way of approaching apexification and provides a glimpse at exciting new horizons in endodontics and tissue engineering. I was recently asked by a colleague if I had interest in placing implants. I explained to him that while implants provide a valuable service to replace missing teeth, as an endodontist, I am dedicated to preserving the natural tooth. I am grateful to work with so many great implant surgeons, but I expect there will come a day when real teeth are replaced with real, bioengineered teeth.
Here is an example of pulpal regeneration performed at Superstition Springs Endodontics.
This young patient had tooth #8 avulsed. The tooth was stored in milk <1hr>
Tooth #8 was accessed, pulpal tissue removed with minimal filing and copious NaOCl irrigation.
Coronal MTA plug placed w/ cotton & resin access filling.
At 2 months, the periapical lesion is gone and tooth is asymptomatic.
At 4 year recall, the apex has closed, the dentinal walls of the root have thickened and the tooth is asymptomatic and functional.
The protocol for this procedure is still being developed. The American Association of Endodontists is building a database regenerative cases to aid in the development of this protocol.
The upcoming Inner Space Seminar entitled, "It's Alive! Pulpal Regeneration" will review concepts in stem cell therapy, current accepted treatment protocol for pulpal regeneration and additional case reports of pulpal regeneration.