Moving Past Apexification: How Regenerative Endodontics Saves Fragile, Immature Permanent Teeth

Introduction:
Regenerative endodontic procedures (REPs) have emerged as a biologically based option for managing necrotic immature permanent teeth with open apices. Traditional apexification using calcium hydroxide or mineral trioxide aggregate (MTA) successfully resolves infection but fails to stimulate root development, often leaving teeth with thin, fracture-prone walls. By leveraging stem cells, scaffolds, and growth factors, REPs aim to encourage continued root maturation. While autologous scaffolds like platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) show clinical promise, achieving true histological pulp regeneration and reliable pulp sensibility remains challenging.

Methods:
This case review examines a series of immature permanent teeth presenting with necrotic pulps and wide open apices. Ideal cases were selected based on the presence of thin canal walls that precluded safe rotary instrumentation. Patients with severe structural crown damage, antibiotic paste allergies, or compliance issues were excluded. The clinical protocol involved minimal mechanical instrumentation, reliance on topical intracanal medicaments for disinfection, and the induction of a scaffold to promote tissue biogenesis.

Results:
The reviewed cases demonstrated consistent resolution of periapical lesions and progressive root development. The utilization of PRP or PRF scaffolds contributed to noticeable lateral dentin wall thickening and apical closure over the follow-up periods. However, post-operative pulp vitality testing showed inconsistent responses, underscoring the ongoing unpredictability of complete neurovascular regeneration despite clinical success.

Conclusion:
REPs offer a distinct structural advantage over conventional apexification by improving root integrity in immature teeth. Nevertheless, more standardized protocols and longitudinal studies are necessary to establish predictable, long-term outcomes.