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 Table of Contents  
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 47-49

Collagen as a scaffold in regenerative endodontic treatment of necrotic immature permanent tooth

Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication30-Jul-2015

Correspondence Address:
Prof. Neelam Mittal
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2454-3160.161803

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Regenerative endodontics is now an established treatment modality for necrotic immature permanent teeth. This case report describes the treatment of a necrotic immature permanent maxillary central incisor with crown fracture using a regenerative approach instead of the conventional apexification procedure. The necrotic root canal was gently debrided, irrigated and then medicated with triple antibiotic paste. At 1-month recall appointment, the tooth was asymptomatic. Bleeding was induced by filing the canal beyond the apex and collagen was placed along with induced blood clot. After 12 months follow-up, healing of periapical lesion, progressive thickening of the root canal walls, and apical closure was radiographically evident. This suggests that regenerative endodontic treatment is an appropriate treatment modality for the management of necrotic immature permanent teeth. Collagen scaffold combined with bleeding induction results in apical closure in immature teeth.

Keywords: Collagen, immature tooth, open apex, scaffold

How to cite this article:
Mittal N, Sharma S. Collagen as a scaffold in regenerative endodontic treatment of necrotic immature permanent tooth. Saint Int Dent J 2015;1:47-9

How to cite this URL:
Mittal N, Sharma S. Collagen as a scaffold in regenerative endodontic treatment of necrotic immature permanent tooth. Saint Int Dent J [serial online] 2015 [cited 2021 Jan 22];1:47-9. Available from: https://www.sidj.org/text.asp?2015/1/1/47/161803

Endodontic infection or physical trauma of a tooth with an immature apex can lead to pulp necrosis, incompletely formed roots with wide open apices, reduced root length, and thin and fragile dentinal walls. Banchs and Trope [1] described revascularization procedure for the treatment of a necrotic immature mandibular second premolar with an open apex and a large apical lesion. They proposed a clinical protocol for revascularization of infected immature teeth that would stimulate pulp regeneration and promote apical closure.

Biodegradable scaffolds are one of the important factors for tissue engineering. An empty canal space will not support in-growth of new tissue from the periapical area on its own. [2] A scaffold provides the framework for cell growth and differentiation at a local site. Collagen is the major component in extracellular matrices, and provides great tensile strength in tissues. As a scaffold, collagen allows for easy placement of cells and growth factors and allows for replacement with natural tissues after undergoing degradation. [3] In 1977, Nevins et al. reported an immature partially vital maxillary lateral incisor which was totally pulpectomized and filled with a collagen gel. Radiographic results demonstrated complete root development and hard tissue formation in the canal. [4] The degradation rate of collagen is less controllable than that of synthetic scaffolds. Furthermore, collagen may cause an antigenic reaction as commercially available collagen is obtained from animal sources. However, its excellent biocompatibility and bioactivity make collagen the preferred scaffold of tissue engineers. [5]

The US Food and Drug Administration (FDA) has approved collagen scaffolds for some medical treatments, which suggests these scaffolds could be approved by the FDA for endodontic regeneration in the future. [6] The presented case reports successful management of an immature necrotic permanent tooth by a regenerative procedure using collagen as scaffold.

  Case Report Top

A 13-year-old female reported with the chief complaint of spontaneous pain in upper front tooth and discoloration of the same tooth. She had a history of trauma at the age of 10 years. Clinical examination revealed Ellis class I fracture in tooth number 21. Tooth number 21 gave no response to thermal tests or electric pulp test. It was non-tender. Periodontal probing depths were within normal limits. Tooth had an open root canal with a cotton pellet placed in it. Intraoral periapical radiograph revealed periapical radiolucency and increased periodontal ligament space width in relation to tooth number 21. It also revealed immature root in tooth number 21 and access opening due to a previously attempted root canal [Figure 1]. On the basis of clinical and radiographic findings, diagnosis of necrotic pulp with asymptomatic apical periodontitis was made for tooth number 21. It was decided that the involved teeth be managed by a regenerative endodontic procedure using collagen as the scaffold.
Figure 1: Preoperative radiograph

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Detailed treatment protocol was explained and written informed consent was taken from patient's father. Under rubber dam isolation, the already present access cavity was refined on tooth number 21. The necrotic pulp was removed with a barbed broach. Working length was determined, and canal was copiously irrigated with 2.5% NaOCl. Triple antibiotic paste was placed in the canal and the access cavity was sealed with temporary restorative material (Cavit). The patient was recalled after 4 weeks.

At the recall visit, tooth number 21 was asymptomatic. Local anesthesia was achieved with 2% xylocaine without any vasoconstrictor. Under rubber dam isolation, the temporary restoration was removed and the antibiotic mixture was washed out by using 2.5% NaOCl. The canal was dried. Blood clot was formed in the canal by intentional periapical filing and collagen sponge [Figure 2] was placed in the disinfected root canals using endodontic plugger. Access cavity was sealed with restorative glass ionomer cement. For the next 12 months, tooth number 21 was evaluated clinically and radiographically. Clinically, the patient was asymptomatic. IOPA radiograph showed complete healing of periapical radiolucency around tooth number 21, thickening of root canal walls and apical closure, although increase in root canal length was not appreciable [Figure 3]. The tooth was restored with metal ceramic crown for esthetic improvement.
Figure 2: Commercially available collagen scaffold

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Figure 3: Radiograph at 12 months follow-up

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  Discussion Top

Several case reports have documented revascularization of necrotic root canal systems by establishing bleeding into the canal system via overinstrumentation. [1],[7] A collagen scaffold will naturally degrade and allow for tissue regeneration. A collagen scaffold was selected because of its ease of placement and similarity to the most common collagen component of normal human dental pulp. Yamauchi et al. [8] demonstrated that the use of a cross-linked collagen scaffold with bleeding induction, in teeth with incomplete root development and periapical periodontitis, significantly increased the formation of mineralized tissues. Improved healing of the apical periodontitis in the collagen scaffold group could have to do with the osteoinductive properties of the scaffold.

Hence, an insoluble collagen sponge was used as a scaffold. The inherent nature of collagen sponge provides a number of potential advantages as a scaffold for tooth-tissue engineering. Since dentin consists largely of collagen type I, the collagen sponge scaffold may directly enhance differentiation of the precursor mesenchymal cells. The higher alkaline phosphatase activity on collagen sponge scaffolds supports the possibility that this scaffold promotes cell differentiation. In vivo complete tooth morphology with root-like structures was exhibited by Sumita et al. in the implants obtained from the collagen sponge scaffolds. [9] It is believed that the collagen fibers function as a "trap" for osteoinductive factors such as bone morphogenetic protein, transforming growth factor-b, insulin-like growth factor-I, and other cytokines and thus mediate osteogenic differentiation. [10]

Thibodeau et al. [2] stated that the immature roots treated with a blood clot after disinfection had better outcomes than those that did not include a blood clot in the canal space (only collagen was used). Thus, inclusion of the blood clot with its constituent growth and differentiation factors are important for successful revascularization after disinfection. Thus, in this case, collagen was used along with blood clot.

In this case, apical closure and thickening of dentinal walls is evident but root lengthening is not appreciable. In conclusion, this procedure results in restoration of some of the functional properties of involved teeth and should be considered as a viable option in treating such cases.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: New treatment protocol? J Endod 2004;30:196-200.  Back to cited text no. 1
Thibodeau B, Teixeira F, Yamauchi M, Caplan DJ, Trope M. Pulp revascularization of immature dog teeth with apical periodontitis. J Endod 2007;33:680-9.  Back to cited text no. 2
Prescott RS, Alsanea R, Fayad MI, Johnson BR, Wenckus CS, Hao J, et al. In vivo generation of dental pulp-like tissue by using dental pulp stem cells, a collagen scaffold, and dentin matrix protein 1 after subcutaneous transplantation in mice. J Endod 2008;34:421-6.  Back to cited text no. 3
Nevins A, Wrobel W, Valachovic R, Finkelstein F. Hard tissue induction into pulpless open-apex teeth using collagen-calcium phosphate gel. J Endod 1977;3:431-3.  Back to cited text no. 4
Kim NR, Lee DH, Chung PH, Yang HC. Distinct differentiation properties of human dental pulp cells on collagen, gelatin, and chitosan scaffolds. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:e94-100.  Back to cited text no. 5
Chandrahasa S, Murray PE, Namerow KN. Proliferation of mature ex vivo human dental pulp using tissue engineering scaffolds. J Endod 2011;37:1236-9.  Back to cited text no. 6
Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol 2001;17:185-7.  Back to cited text no. 7
Yamauchi N, Yamauchi S, Nagaoka H, Duggan D, Zhong S, Lee SM, et al. Tissue engineering strategies for immature teeth with apical periodontitis. J Endod 2011;37:390-7.  Back to cited text no. 8
Sumita Y, Honda MJ, Ohara T, Tsuchiya S, Sagara H, Kagami H, et al. Performance of collagen sponge as a 3-D scaffold for tooth-tissue engineering. Biomaterials 2006;27:3238-48.  Back to cited text no. 9
Gassling V, Douglas T, Warnke PH, Açil Y, Wiltfang J, Becker ST. Platelet-rich fibrin membranes as scaffolds for periosteal tissue engineering. Clin Oral Implants Res 2010;21:543-9.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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