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By Tawfik H.; Abu- Seida *, A.M .; Hashem , A.A. and Nagy, M.M. Comparative Study between Revascularization and MTA Apical Plug for Treatment of Immature Permanent Teeth with Necrotic Pulp in Dogs: Part II Histopathological Assessment. Introduction. Introduction.

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by tawfik h abu seida a m hashem a a and nagy m m

Tawfik H.; Abu-Seida*, A.M.; Hashem, A.A. and Nagy, M.M.

Comparative Study betweenRevascularization and MTA Apical Plug for Treatment of Immature Permanent Teeth with Necrotic Pulp in Dogs: Part IIHistopathological Assessment

  • Treatment of immature permanent teeth with pulp necrosis and apical pathosis constitutes a big challenge for endodontists. These conditions are commonly encountered in cases of trauma to the anterior teeth or untreated carious lesions. Such conditions present much difficulty, not only in root canal debridement and obturation, but also for the thin dentinal walls increasing the risk of subsequent fracture
  • Management of such cases was previously done by apexification procedures using calcium hydroxide
  • More recently, placement of apical plugs has been advocated by many authors. MTA proved to be excellent in this aspect; however apical plugs do not solve the problem of the thin and weak dentinal root canal walls
  • Periapical tissues in immature teeth are rich in blood supply and contain stem cells that have a great potential to regenerate in response to tissue injury
  • There are three key elements for tissue regeneration. First, the adult stem cells which have the ability for proliferation and differentiation. Second, the scaffolds; which are three dimensional structures that support cell organization and vascularization. Third, the growth factors which are the extracellular secreted signals governing morphogenesis.
  • Revascularization protocol depends on the regenerative capacity of periradicular tissues which acts as an endogenous source of stem cells, growth factors and fibrin blood clot as a natural scaffold.
  • Bacterial eradication from the canal space is essential for successful revascularization procedure. Research with antibiotics revealed that a combination of metronidazole, minocycline and ciprofloxacin can be effective against common dental pathogens in vitro and in vivo
  • Several case reports have been published concerning revascularization procedures. However, few experimental studies have been done evaluating the histologic characterization of the regenerated tissues. Also lack of randomized clinical trials prevents widespread application of this treatment protocol.
aim of the study
Aim of the study
  • The aim of the present investigation was to assess histologically the regenerative potential of young permanent immature teeth with necrotic pulps following different treatment protocols namely; Orthograde apical plug using MTA, revascularization, and revascularization enhanced with growth factor

Research ethics

The Present Research was approved by:

Faculty of Dentistry, AinShams University


Faculty of Veterinary Medicine, Cairo University


materials and methods2
Materials and Methods
  • The triple antibiotics
  • Paste:
    • Metronidazole
    • 500 mg tablets
    • Ciprofloxacin
    • 250 mg tablets
    • Doxycycline
    • 100 mg capsules +
    • Normal Saline
materials and methods5
Materials and Methods
  • Subgroup (a): MTA apical plug 

MTA was mixed and inserted apically into the canal. Glass Ionomer filling was used to seal the remaining part of the access cavity

materials and methods6
Materials and Methods

Sub group (b): Revascularization by blood clot

Hand file size #60 was inserted past to the canal terminus until bleeding was induced to fill the canal space. Access cavity was then sealed as mentioned.

materials and methods7
Materials and Methods
  • Subgroup(c): Revascularization by blood clot+ injectable scaffold:
  • 300µl phosphate buffered saline+150 µg of basic Fibroblast Growth Factor.
  • The suspension was dropped onto 2mg dried gelatin hydrogel.
  • Induction of bleeding was done as described before then the prepared hydrogel was inserted into the canals. Access cavities were then sealed as mentioned.
materials and methods8
Materials and Methods
  • Subgroup (d): MTA over empty canal:

MTA orifice plug (2-3mm) was used to seal the empty canal orifice covered by a small wet cotton pellet. Access cavity was then sealed using glass ionomer filling

materials and methods11
Materials and Methods

Histopathologic evaluation:

  • Inflammatory cell count.
  • Bone / Root resorption‎(Scores: 0,1,2)
  • Presence or absence of vital tissues inside the pulp space and their extent (Scores: 0,1,2,3)
  • Presence or absence of new hard tissue (Scores; 0,1,2)
  • Apical closure(Scores; 0,1,2)‎
materials and methods12
Materials and Methods
  • Statistical analysis:

Data were collected, tabulated and statistically analyzed using statistical analysis software SPSS


Photomicrograph showing mild inflammatory cell infiltration (score 1) (X200) subgroup IIa

Photomicrograph showing dense inflammatory cells infiltration , numerous dilated blood vessels and edema (X400) in subgroup Ib

Photomicrograph showing moderate inflammatory cells infiltration (score 2) (X400) subgroup Ic


Photomicrograph showing tissue in-growth with apical root resorption (x100) group III subgroup e

Photomicrograph showing apical root resorption (x200) in subgroup Ib


Photomicrograph showing tissue in-growth up to apical third of the root canal in subgroup IIIb


Photomicrograph showing newly deposited hard tissue in subgroup IIIb(X400)

Photomicrograph showing hard tissue deposition in subgroup IIIa(X40)

  • Both treatment protocols; MTA apical plug and revascularization were successful treatment option with regard to closure of open apices.
  • The revascularization procedure allowed the continued development of roots in teeth with necrotic pulps.
  • The use of artificial scaffold is not essential for repair
  • Revascularization procedure induce repair rather than regeneration of pulp tissue