Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth.

www.ijihresearch.com a NEXUS Science Publishing publication doi.org/10.5281/zenodo.17850970 Volume 1, número 1 – nov/dez 2025 Literature Review PULP REVASCULARIZATION: A REGENERATIVE POSSIBILITY IN THE TREATMENT OF NECROTIC IMMATURE TEETH Revascularização pulpar: uma possibilidade regenerativa na terapêutica de dentes imaturos necróticos Wândrey Vinícius Mendanha Lima1 ; Stephany Luiza Dias Gomes1 ; Janaina Borges da Rocha Cardoso2 ; William Eduardo Pirola2,3 ; Késsia Suênia Fidelis de Mesquita Guimarães2 ABSTRACT Introduction: Pulp revascularization in necrotic immature teeth has been used in the regeneration of dental tissues. Knowledge of this technique by dentists is necessary to offer better conditions for the longevity of teeth to patients. Objective: To highlight current bibliographic findings on regenerative endodontic procedures through pulp revascularization in young teeth with compromised pulp. Method: A narrative literature review was conducted using bibliographic research in the electronic databases PubMed, Virtual Health Library (VHL), and Google Scholar, using the search strategy with the descriptors "pulp regeneration," "pulp revascularization," "regenerative endodontics," and "immature teeth" and their corresponding terms in Portuguese. Inclusion criteria included original scientific research articles in humans and systematic reviews, without time limits, with full text in English and Portuguese. Results: Although considered minimally invasive, several techniques, irrigating solutions, and intracanal medications show promise for performing pulp revascularization. Conclusion: The best method for performing pulp revascularization in necrotic immature teeth depends on the need, the operator's skill, or the complexity of the case. Palavras-chave: Endodontics, Pulp necrosis, Regeneration. 1Acadêmico(a) do Curso de Odontologia do Centro Univeristário de Goiatuba, UniCerrado, Goiatuba-GO, Brazil 2Professor(a) do Curso de Odontologia do Centro Univeristário de Goiatuba, UniCerrado, Goiatuba-GO, Brazil 3Professor do Curso de Odontologia do Centro Univeristário de Rio Preto, UNiRP, São José do Rio Preto-SP, Brazil Autor de correspondência: Késsia Suênia Fidelis de Mesquita Guimarães - [email protected]du.br INTERNATIONAL JOURNAL OF INTEGRATIVE HEALTH RESEARCH, vol.1 n1, Publication date Dec 8, 2025 ISSN Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth Lima WVM, Gomes SLD, Cardoso JBR, Pirola WE, Mesquita-Guimarães KSF 18 RESUMO Introdução: A revascularização pulpar em dentes imaturos necróticos tem sido utilizada na regeneração dos tecidos dentários. O conhecimento da técnica pelos cirurgiões-dentista se faz necessário para oferecer melhores condições de longevidade dos dentes aos pacientes. Objetivo: Destacar os achados bibliográficos atuais sobre os procedimentos endodônticos regenerativos, por meio de revascularização pulpar em dentes jovens, com polpa comprometida. Método: Foi realizada uma revisão narrativa da literatura por meio de pesquisa bibliográfica consultando as bases eletrônicas de dados PubMed, Biblioteca virtual da Saúde (BVS) e Google Acadêmico, utilizando a estratégia de busca por meio dos descritores “pulp regeneration”, “pulp revascularization”, “regenerative endodontics” e “immature teeth” e correspondentes em português. Como critérios de inclusão, foram utilizados artigos científicos de pesquisas originais em seres humanos e revisões sistemáticas, sem limite temporal, com texto na íntegra nos idiomas inglês e português. Resultados: Embora sejam consideradas pouco invasivas, existem várias técnicas, soluções irrigadoras e medicamentos intracanais promissoros para execução da revascularização pulpar. Conclusão: O melhor método de execução de revascularização pulpar em dentes imaturos necróticos depende da necessidade, capacidade do operador ou complexidade do caso envolvido. Palavras-chave: Endodontia, Necrose pulpar, Regeneração. INTRODUCTION Pulp alterations in young permanent teeth, also called immature teeth (MAHLA, 2016), can lead to the process of pulp necrosis. The loss of vitality directly affects the continuation of root development, which results in short roots, very thin walls, and increases the chances of fractures (GUERRERO et al., 2018). Endodontic treatment in these teeth is considered a major challenge, because in addition to the dentinal walls presenting as more fragile, there is a lack of natural sealing in the apical region, which makes it difficult to obtain good chemical-mechanical preparation and obturation with the intention of achieving a hermetic seal (MAHLA, 2016). Some treatments have been suggested for immature permanent teeth with compromised pulp, involving the apexification technique, which consists of inducing the formation of an apical barrier through an intracanal medication (RAFTER, 2005), such as calcium hydroxide [Ca (OH)2] and Mineral Trioxide Aggregate (MTA) (WIGLER et al., 2013). However, it is suggested that such techniques resolve the infection but do not stimulate continuous root development, which remains with thin, fragile, and short dentinal walls (ALY et al., 2019; PEREIRA et al., 2021). Additionally, the permanence of Ca (OH)2 in the tooth root may cause weakening due to hygroscopic and proteolytic properties (WIGLER et al., 2013). Regenerative endodontics has become a highlight, with innovations involving modern and effective approaches for the treatment of teeth with incomplete rhizogenesis. Pulp revascularization is a recent and promising technique that is in evidence for preserving biological principles, the possibility INTERNATIONAL JOURNAL OF INTEGRATIVE HEALTH RESEARCH, vol.1 n1, Publication date Dec 8, 2025 ISSN Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth Lima WVM, Gomes SLD, Cardoso JBR, Pirola WE, Mesquita-Guimarães KSF 19 of minimizing the treatment time of immature teeth (ALBUQUERQUE, 2012), and allowing the regeneration of dental tissues (ALCALDE et al., 2014) through the new insertion of blood vessels and capillaries inside the root canal (ESTRELA et al., 2013; EL ASHIRY et al., 2016; GALLER, 2016), enabling the continuity of root development (ALCALDE et al., 2014). This form of apexification also restores correct apical morphology, reinforces the integrity and mechanical resistance of roots through hard tissue deposition (ESTRELA et al., 2013; ALY et al., 2019), enables the replacement of pulp-dentin complex cells, vital functionality of the pulp (EL ASHIRY et al., 2016; GALLER, 2016; JUNG et al., 2019), immune response against bacterial aggressions, toxins, and pain perception (EL ASHIRY et al., 2016; GALLER, 2016). Given the constant evolutions in procedures aiming at pulp revascularization in immature teeth with incomplete rhizogenesis and the great variety of treatment protocols with this therapy, it is necessary to survey studies that compare current execution methods in order to reach the most adequate path for success. METHODOLOGY To execute the proposed objectives, an integrative literature review will be carried out, in which bibliographic research will be performed by consulting the electronic databases PubMed, Virtual Health Library (VHL), and Google Scholar, using the search strategy via the descriptors “pulp regeneration”, “pulp revascularization”, “regenerative endodontics”, and “immature teeth” and their correspondents in Portuguese. The established inclusion criteria will be: scientific articles of original research in humans and systematic reviews, published in the period from 2020 to 2025, with full text in English and Portuguese. Excluded from the research will be: narrative literature review articles, letters to the editor, in vitro research, original research involving animals, works published outside the determined timeframe, those not written in the mentioned languages, and those that do not fit the subject. LITERATURE REVIEW Pulp Revascularization Endodontic treatment of teeth presenting incomplete rhizogenesis is a challenging procedure due to the presence of thin root walls, wide canals, and open apical foramen, making chemical and mechanical preparation of root canals difficult (CARNAÚBA et al., 2018). Facing this difficulty, pulp revascularization arises as an option for the treatment of immature teeth, being a technique that stimulates apex development and root maturation through minimal instrumentation or, in some cases, no instrumentation, placement of intracanal medication, and induction of a blood clot or use of platelet-rich plasma (NAMOUR; THEYS, 2014; CARNAÚBA et al., 2018). In the year 2016, the American Association of Endodontists (AAE) established pulp revascularization as the procedure of choice for INTERNATIONAL JOURNAL OF INTEGRATIVE HEALTH RESEARCH, vol.1 n1, Publication date Dec 8, 2025 ISSN Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth Lima WVM, Gomes SLD, Cardoso JBR, Pirola WE, Mesquita-Guimarães KSF 20 endodontic treatment in immature teeth, considering three objectives as parameters for success: elimination of present symptoms and induction of bone healing, increase in root thickness and length, and positive tooth response to sensitivity tests (SANTOS et al., 2022). Dental Tissue Engineering To achieve success in the revascularization procedure, it is necessary that stem cells, growth factors, and a scaffold for newly formed tissue are present inside the canal (NAZZAL; DUGGAL, 2017). The procedure environment must also be taken into account, as a good vascular supply of nutrition and tissue oxygenation is essential (MALHOTRA; MALA, 2012). Stem cells, also called progenitors, are capable of dividing and producing other progenitor cells, which differentiate into specific cells or tissues. In the oral cavity, these cells are present in the dental pulp, in human apical papilla stem cells, and in the periodontal ligament. Depending on the need, they have the capacity to differentiate into odontoblasts or fibroblasts (BRONCKAERS et al., 2013). The growth factors present in the blood clot and dentin matrix are vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFB), fibroblast growth factor (FGF), and insulin-like growth factor (IGF). These factors are associated with various functions, such as increased angiogenesis, vasculogenesis, stimulation of proliferation, and differentiation of odontoblasts (JUNG et al., 2019 apud SILVA et al., 2023). The scaffold is the location that must support the growth of cells and tissues, allowing them to migrate and adhere to the structure, enabling their cellular differentiation through growth factors and the provided structure (ZHANG et al., 2012). The blood clot, which is obtained through induced bleeding in the canal, is a scaffold option (ZBAŃSKA et al., 2021); however, it possesses many hematopoietic cells capable of releasing toxic intracellular enzymes and may hinder stem cell survival at the site (JAZAYERI et al., 2020). Platelet-Rich Fibrin (PRF) emerged as an alternative due to its rich supply of growth factors, having autologous components from patient blood (SHIVASHANKAR et al., 2017). Case Selection To perform pulp revascularization, it is necessary to select criteria that make the procedure viable; that is, necrotic permanent teeth must be in the stage of incomplete rhizogenesis, with or without periapical lesions; teeth must not require a post and core for definitive restoration; patients and parents must have good adherence and commitment to treatment, and patients must not present allergies to the medications and antibiotics used (WEI et al., 2022). Clinical Protocol The methods used for pulp revascularization are minimally invasive INTERNATIONAL JOURNAL OF INTEGRATIVE HEALTH RESEARCH, vol.1 n1, Publication date Dec 8, 2025 ISSN Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth Lima WVM, Gomes SLD, Cardoso JBR, Pirola WE, Mesquita-Guimarães KSF 21 (FEDELE; KAHLER; VENKATESHBABU, 2019) and possess some variations in clinical protocols; however, the main stages consist of minimal instrumentation of the canal wall; disinfection of canals with irrigating solutions; dressing with intracanal medication; induction of bleeding in the canal space and creation of the blood clot or use of scaffolds with PRF; coverage with bioceramic materials; and effective coronal sealing (WEI et al., 2022). Irrigating Solutions Because mechanical preparation of root canals is extremely cautious due to very thin walls, the use of chemical solutions for canal disinfection is of utmost importance (ALCALDE et al., 2014). Solutions must be bactericidal and bacteriostatic and have minimal cytotoxic effect so as not to hinder progenitor cells and fibroblasts regarding survival and proliferation at the site (NAMOUR; THEYS, 2014). Sodium hypochlorite (NaOCl) and chlorhexidine digluconate are available, with the former being the preferred option, usable at a concentration of 2.5% in the revascularization procedure. Furthermore, the use of ethylenediaminetetraacetic acid (EDTA 17%) is important because, besides removing the smear layer from the canal, it assists in the release of growth factors present in the dentin matrix (ALCALDE et al., 2014). Due to the toxicity of hypochlorite, irrigation with saline solution is recommended after its use, acting to neutralize toxic substances generated inside the canal (SANTOS et al., 2019). Intracanal Medication The intracanal medication stage has great importance in treatment phases for the elimination of microorganisms present in the canal, improving infection. Two types of medications can be used for the protocol: triple antibiotic paste and calcium hydroxide (SANTOS et al., 2018). Triple antibiotic paste is composed of metronidazole, ciprofloxacin, and minocycline and uses propylene glycol as a vehicle (PACHECO; VILLELA; MARTINS, 2023); however, due to minocycline, it may cause pigmentation in the dental crown, and additionally possesses cytotoxicity, development of resistance, and difficulty of removal from the canal (ALCALDE et al., 2014). Thus, calcium hydroxide [Ca(OH)2] for the revascularization protocol is an effective and safe medication to be used (LIN; KAHLER, 2017), inducing pulp cells to differentiate, forming dentin-like tissue at the site (NAGATA et al., 2014). Revascularization Techniques American Association of Endodontists Technique According to the document “AAE Clinical Considerations for a Regenerative Procedure” revised in 2021, the suggested protocol for pulp revascularization cases consists of the following steps: 1st appointment: local anesthesia with anesthetic containing vasoconstrictor, absolute isolation with rubber dam, and coronal access. INTERNATIONAL JOURNAL OF INTEGRATIVE HEALTH RESEARCH, vol.1 n1, Publication date Dec 8, 2025 ISSN Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth Lima WVM, Gomes SLD, Cardoso JBR, Pirola WE, Mesquita-Guimarães KSF 22 Irrigation with 20 ml of sodium hypochlorite (NaOCl), indicated in concentrations of 1.5% to 3% using a syringe and needle system that minimizes extravasation of the solution into the periapical space, such as closed-end needles with side openings. Irrigation with 20 ml of saline solution or EDTA 17%, with the needle positioned about 1mm from the root end to decrease toxicity in apical tissues. Dry the canal with absorbent paper points. Application of intracanal medication with calcium hydroxide paste or triple antibiotic paste, leaving it below the cementoenamel junction; after that, seal with 3-4 mm of temporary material and wait 1-4 weeks. 2nd appointment (1-4 weeks after first session): evaluate the response to initial treatment; if there are signs/symptoms of persistent infection, continue with intracanal medication or change the antimicrobial method. In case of success, with control of infection and painful symptomatology, anesthesia is performed with Mepivacaine 3% without vasoconstrictor to prevent vasoconstriction from decreasing clot formation, followed by absolute isolation, gentle and abundant irrigation with 20 ml of EDTA 17%, and drying of the canal with absorbent paper points. Abundant bleeding must be provoked in the canal through excessive instrumentation with rotation of a pre-curved Kerr file 2 mm beyond the apical foramen aiming to fill the entire canal with blood up to the cementoenamel junction. After that, leave the clot 3 mm below the junction and place a resorbable collagen matrix over it. MTA can be used as covering material; however, as it is being associated with discoloration, Biodentine R is a possible alternative. Apply a 3-4 mm layer of glass ionomer over the covering material, polymerize for 40 seconds, and restore definitively. Technique using Platelet-Rich Fibrin In an attempt to overcome negative points and adverse effects of using the blood clot, Autologous Platelet Concentrates (APCs) gain space in revascularization techniques, having good regenerative potential (DARWISH; AZIZ; SADEK, 2025). Studies demonstrate that PlateletRich Fibrin (PRF), one of the types of APCs, is capable of increasing the migration of apical papilla stem cells, stimulating proliferation and differentiation in the region to be revascularized (BI et al., 2020). PRF preparation consists of collecting 9 ml of the patient's blood via the cubital vein, placed in sterile tubes, which are centrifuged for 12 minutes at a speed of 2700 rpm. Three layers are formed inside the tube: a layer with erythrocytes, a central layer of PRF clot, and the most superficial layer corresponding to acellular plasma. The layer of interest for revascularization is the PRF clot; thus, it is separated from the remaining two and compressed in a PRF container. After preparation, the PRF is placed inside the canal and condensed apically (BAKHTIAR et al., 2017). The technique using PRF possesses a treatment protocol very similar to the use of the INTERNATIONAL JOURNAL OF INTEGRATIVE HEALTH RESEARCH, vol.1 n1, Publication date Dec 8, 2025 ISSN Pulp revascularization: a regenerative possibility in the treatment of necrotic immature teeth Lima WVM, Gomes SLD, Cardoso JBR, Pirola WE, Mesquita-Guimarães KSF 23 clot, differing only in the type of scaffold that will be used for revascularization, such that the first appointment and the initial part of the second follow the same sequence, including the use of Mepivacaine 3% without vasoconstrictor. After drying the canal, PRF is placed inside the canal and condensed apically with a manual condenser to subsequently place a resorbable collagen matrix. MTA or Biodentine R is applied as covering material, a 3-4 mm layer of glass ionomer, polymerized for 40 seconds, and restored definitively (AMERICAN ASSOCIATION OF ENDODONTICS, 2021). Post-operative Follow-up It is indicated that follow-up after the revascularization procedure be at 6, 12, and 24 months during the first two years and annually after this period (AMERICAN ASSOCIATION OF ENDODONTICS, 2021). During evaluations, some factors are observed through clinical and radiographic examination: presence of pain, soft tissue edema, or presence of a sinus tract in the region, observed between the first and second appointment, and resolution of radiolucency in the apical region, observed 6 to 12 months after treatment. Regarding the tooth, the increase in root wall width is evaluated, generally between 12 and 24 months after treatment, which occurs before the increase in root length, and finally, a positive response to pulp vitality tests is observed. Cone Beam Computed Tomography (CBCT) is an excellent imaging resource that may be indicated for more precise evaluation of the result. The degree of success of the regenerative procedure is evaluated by observing symptom elimination, induction of bone healing, increase in root thickness and length, and positive tooth response to sensitivity tests, which are the objectives of pulp revascularization in immature teeth (AMERICAN ASSOCIATION OF ENDODONTICS, 2021). CONCLUSION The best method for performing pulp revascularization in necrotic immature teeth depends on the need, the operator's skill, or the complexity of the case,. Therefore, the dental surgeon must correctly select the case and know the techniques and materials used well to obtain a good clinical prognosis. REFERENCES ALBUQUERQUE, M. T. P. Protocolos de revascularização pulpar. 2012. Monografia de conclusão de curso (Especialização em Endodontia). Faculdade de Odontologia de Piracicaba/UNICAMP, Piracicaba, SP, 2012. ALCALDE, M. P. et al. Revascularização pulpar: considerações técnicas e implicações clínicas. Salusvita, v. 33, n. 3, p. 415-432, 2014. ALY, M. 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