Regenerative endodontic procedures (REPs) selecting a case

Selection indicators for a case

The REPs is indicated in cases that meet the following requirements: (a) necrotic permanent teeth with incomplete root formation, regardless of the presence of periradicular lesions; (b) no need for a post or core for the final restoration; (c) good compliance from the patient or parent; and (d) patients who are not allergic to the medications or antibiotics used in the procedures.

In some situations, the REPs is not applicable, such as when teeth are immediately replanted after avulsion, when tooth isolation is insufficient, when teeth have extensive coronal tissue loss and need a post-restoration, or when teeth have endodontic-periodontal lesions.

Case selection considerations 

the overall situation, When developing a treatment plan, the general state of health should be taken into account first. The physical health status of patients can be evaluated using the American Society of Anesthesiologists' (ASA) Health Classification System. Patients who are ASA 1 and ASA 2 categories can be taken into consideration for one of 69 REPs.

Patients with immune disorders like poorly managed diabetes or long-term hormone drug use may have trouble controlling the infection of their root canals. Additionally, it is not advised to perform REPs on patients who have poorly controlled hypertension, a recent (within three months) myocardial infarction, a cerebrovascular accident, or coronary artery disease.

In the following situations, REPs should exercise caution: (a) mental health conditions; (b) dental phobia; or (c) excessive anxiety.

Age 

In the cases that have been reported, age is another systemic factor that REPs take into account. Patients receiving REPs made up more than 90% of those under the age of 17. According to a clinical study, REPs can be implemented in patients of any age between 9 and 18 years old, but younger patients (9 to 13 years old) were better candidates for REPs than older patients (14 to 18 years old). This was due to the younger patient group's (9 to 13 years old) better treatment outcomes and greater root development than the group of 14 to 18-year-old patients. Additionally, a few studies found that REPs performed on patients older than 18 years old did not successfully stimulate the development of roots in immature teeth. Studies showing that the proliferative and differentiation potential of MSCs decreased with aging provide evidence that this may be due to younger patients having a higher capacity for healing or stem cell regenerative potential. The stage of root development is a crucial element that is related to age. Since the apical papilla is a rich source of MSCs, the large diameter of the open apex promotes the ingrowth of tissue into the root canal space. In this sense, it would seem that case selection would be influenced by the patient's age. To clarify the upper age limit for REPs, additional research is necessary.

Clinicians should also be aware that REPs are not recommended for deciduous teeth due to the possibility of interfering with the eruption patterns of succeeding permanent teeth.

The Roots Morphology

According to studies, when choosing cases, it's important to take root morphology into account as well. According to recent studies, teeth with preoperatively wider apical diameters (1 mm) showed greater increases in root thickness, length, and apical narrowing. It's interesting to note that there is still debate over the ideal minimum apical diameter for REPs. Abada et al. demonstrated an increase of the in-growth tissue in the root canals with increased apical diameter, in contrast to Laureys et al. who discovered newly formed tissue in the root canals with the smallest apical diameter ranging between 0.24 mm and 0.53 mm.

Clinical success was also attained in teeth with apical diameters less than 1 mm following REPs based on the results of periapical healing and ongoing root development on both the clinical and radiographic levels, with the highest clinical success rate of 95.65% in teeth with apical diameters of 0.5–1.0 mm. In general, within the confines of the existing literature, REPs may be applicable in teeth with apical diameters as small as 0.24 mm or above. The relationship between root morphology and the outcome of REPs hasn't, however, been proven conclusively.

Following the onset of pulp necrosis, REPs have been at the forefront of treatment recommendations for young permanent teeth at stage 1 (less than half of root formation with open apex), stage 2 (half root formation with open apex), and stage 3 (two thirds of root development with open apex). If the thickness and strength of the roots are sufficient, both apexification and REPs are advised as treatment modalities for root development reaching stages 4 and RCT is advised for teeth that are infringing at stage 5. REPs have recently been carried out on mature teeth (closed apices) with pulp and periapical disease, though. According to a clinical study, REPs can be used to treat mature teeth with significant periapical radiolucency. They were able to resolve clinical symptoms and apical radiolucencies of various sizes, and 50% of the teeth treated with REPs showed a positive response to electric pulp testing. Before applying REPs to mature teeth with apical periodontitis, however, more research-based studies should be conducted.

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MTA APEXIFICATION case 1 apexification steps