Hi everyone, my name, is Dr. Antonio Berto, I’m a full-time in the dentist in Dallas Texas. Today, I’m very excited to talk about a novel procedure called what regeneration. It is true that, back in the seventies, Dr. Legaspi was able to regenerate by table this year, but he was unable to do so when the pork was necrotic.
So today would not be discussing this technique to where we can predictively allow the club to regenerate.
So during this presentation, we’re gonna be talking about what is regenerative endodontics? What is the biological basis for regenerative endodontics therapy?
What are the considerations for clinical regenerative endodontics procedure, and what cool regenerative endodontics looks like in the future? So if we were able to bring a necrotic case into a vital case that will be phenomenal.
I truly believe that in the near future, that’s going to be definitely a treatment option and what is regenerative endodontics is a biological-based procedure that will allow us to predictably replace a damaged piece of you and restore the normal physiological functions to the port dentin complex.
So, when we look at this case historically, what we will try to do, it’s using multiple visits of calcium hydroxide to obtain up plug epicly and eventually fill the root canal with our carrots, our filling material. The problem with this treatment is that Google need multiple treatments with cosmic oxide.
The patient will have to be compliant and then multiple changes of calcium hydroxide have been shown. The will develop debilitated the mechanical properties of dentin.
Another alternative is doing an MTA black toxification. Where we can in one single visit in the root canal with MTA? The MTA has been proven to allow growth cementum around that area and the studies so up to 95 percent success, but neither of those two techniques are going to allow us to get any quotient on thickness on hand land from the weak roots.
So let’s have a look at this case. This is a case from my friend in Ontario, Canada, barats Bora and did show us how they open a big stood has a huge potential of regeneration.
This number 8 was a ball on the kids grandfather garden and luckily his grandfather he’s a dentist, so he was able to implant the tooth right away and after that, they went to Dr Bora for following up as you can see on the pre-op and the three weeks follow up.
There is no pathology critically, and then I’m five weeks. We can start seeing root development again. There was no need for endodontic treatment and the pulp was able to regenerate by itself. This is a different scenario.
We have already established infection when I’m open to through the epical parent IVs. So, when we think on those three they’re very thin, very prone to fracture, and we’re gonna go through it’s a technique to stimulate new tissue on the inside of the tooth so work when are we gonna do this procedure? First of all, we needed to that is necrotic with an immature apex.
Then we need that pulp space not being needed for post core or final restoration. Definitely a very important thing is that the patient is complying especially their guardian and finally, the patients will not be allergic to any medicines or antibiotics.
As far as the consent form, we’re gonna make two consent form for two appointments, and we’re gonna inform the face in the work on IV using antibiotics and then the possible adverse effects at first staining on the crown or root.
And then the lack of response of treatment, so in the first appointment we’re gonna get a toad now, as we will typically do with local and state here, typically lidocaine and epinephrine.
We can isolate the tooth with our rubber dam, and then we can access with our rubber and our endo CES. We typically do and in this technique we’re gonna rely on the chemicals through this infected tooth.
We don’t want to instrument those very in roots to debilitate them even more so again, we rely whenever he returns to do the disinfection so for us to get us effect effective as possible.
We’re gonna use negative pressure device and there’s multiple negative pressure device in the market. I like to use my own one, since it’s a little bit less complicated and the ones in the market.
The way I did my own, the negative pressure device – it’s just using our regular, so I’m happy right, and then we’re gonna use an open side vented needle like a maxi pro needle, and then we’re gonna use an empty tube of either ultra Color or ads and then a small Navy tip and that’s how we’re gonna set it up.
Who can I ever get with our regular maxi probe and then the suction is gonna come from the apical part of it, and that way we can deliver our arrogance in a very safe way, and then we will place calcium, hydroxide or a low concentration of Our triple antibiotic base delivering to the canal system via syringe and what is the triple antibiotic paste.
It is a mix of ciprofloxacin, metronidazole and minocycline.
My personal recommendation to avoid gram staining is to substitute the clean for augmenting and then on the second appointment. It’s very important that we use anesthesia without epinephrine.
Why is that we’re gonna induce bleeding on the canal, so the vasoconstriction can have a negative effect on the bleeding, so you think on using something like maybe became for that once it to tease.
Now again, we will go back and irrigate really good and as a final step, we want to use cue mix so that we can remove the smear layer and get all our blood clot inside of the tentacle tubules and something very important as well again.
We need to remember that we are relying on the chemical product, a return to disinfect the canal, we’re gonna use the inductive aider for that regards to multi a broken surround and then, before finishing the procedure, to something a little trick that I always like to do to avoid chronic staining, and it’s drying the canals then we’re gonna add the crown.
Then we will use our bond and seal the dentinal tubules on the coronal aspect of the tooth.
So, once we have, that here comes the more critical part of the case. We’re gonna get a hand file like a 30 or 35, and then we’re gonna intentionally go past the apex.
Okay, that’s gonna induce the clearing, and it’s a very critical part. Okay, once without the blood start going coronally, we want that blood to clot around the CJ level and then once we have that my recommendation is to use a collagen plug to prevent the MTA going too far.
Ethically, because we want to keep that MTA as coronal as possible to allow the more apical part to continue follow, and they work to deliver this MTA its basis and the more control we’ll have it with a map system.
Okay, it’s a like a little small amalgam. Plugger, but under a microscope you can have much more control. So, that’s the way we will be delivering the MTA on a very controlled environment and, finally, we’re gonna end up restoring the tooth.
We can put a thin layer of glass ionomer, so we don’t have to wash out the MTA and over the glass ionomer will play some racing or amalgam restorations, so we have seen day, and he made some part of it.
Now, let’s have a look at the real life: okay, this if our patience is a twelve-year-old, female complication, patient, and she came to our office with this open apex tooth when we did our vitality test.
Take two didn’t respond to call and was it slightly sensitive to percussion, so our diagnosis was pol necrosis with synth America without parental ease. When we access the booth, we found basically what we were expecting: a necrotic, bowel blisters. We irrigate we place our medication and that’s the final x-ray and the final picture with a resin type of material. The reason why I chose that color racing material.
We can seal the tooth better. It’s very important. We will talk further to obtain a really good, Cornell seal and then on our second visit again, we irrigate really good wind use, the bleeding we place our collagen matrix and impact the MTA against it and that’s a final x-ray.
So in the MTA and the final restoration, so when we look at the tooth from the pre-op x-ray, so they follow up, we can start seeing some healing and then three months later the apical area was completely resolved and what we were not expecting is this fantastic Result at two years were the tooth seems like a normal tooth, completely developed so again from we went from out basically guarded prognosis and want to get extracted tooth to completely normal guilty tooth, fully develop, responding to a vitality test and that’s our main objective.
When we try to do this type of treatments, so now, let’s talk about some questions that it may arise where the factors for success: what are the clinical outcomes?
What is in the canal space? Is it truly called? What are the potential complications? Let’s talk a little bit about case selection as well, so there’s three very important factors. First, that’s impacting the root canal.
We have stress already the importance of our chemicals to disinfect the root canal.
We’re barely gonna be using our endodontic valves. Second, we’re gonna use a matrix so that we can use the proliferation and differentiation of the pulp TC.
Okay, that’s gonna come from our blood clot and finally, and most importantly, we want to seal our coronal axis as good as possible. Okay and that’s where the MTA and our composite are gonna come into, and then, as far as the outcomes, most of the studies that we have, unfortunately, our case serious.
So level of evidence is not great, but on most of these studies, what we found is That there’s absence of clinical signs and symptoms, these radiographic evidence of resolution of the infection we continuously see root, development and increase in the wall thickness, and a very recent study shows that they’re significantly greater increase in route length and thickness when comparing this treatment to both Calcium hydroxide for MTA pacification and that’s something to be expected.
When should we expect the outcomes? There is a variation between 3 and 21 months for the listen to heal, there’s an average of 8 months for that and then, as far as root development typically is going to happen within the first two years, and here on.
This is the logical slide. We can see what happens inside of the canal, okay, unfortunately, on dog studies, which is where we’ve been able to do so.
What we’re seeing is not true both issue but cement on type of tissue and bone like type of tissue, so those black arrows are cemento sites which are precursors of semental cells, and then the blue line are cement oblast.
Creating cementum were the potential complications. Sometimes, unfortunately, this treatment, similar dental or medical treatment, is not a hundred percent successful.
So, in certain cases we’re gonna be unable to induce bleeding on those cases, I would recommend you to place the medication one more time and bring the patient back.
If the MTA placement goes to a big club, you can always wash it out and try to place it again. We have explained to you how to prevent that by placing the collagen barrier, we have also discussed how to avoid to discoloration, and then we’ll talk in a second about case selection.
So tooth discoloration happens for two reasons: one if we use the tetracycline, and we can change that for augmenting or just do a double antibiotic paste. And then again we mentioned about bonding the coronal part of it with an adhesive to avoid the discoloration as they form.
A holiday that is released from the composite type of materials – and this is something I call Fifty Shades of Grey, because if you don’t get to prevent those we’re gonna have this type of grey discoloration, and since that movie just came not so long ago.
I thought it was funny this situation, something where we can actually counter it back and do internal bleeding, and typically the internal bleaching is gonna, have really good results on it. And finally, let’s talk about case selection in this first case.
It’s a very relatively recent case that I did it’s a one-step revascularisation. There is already literature the journal finder on ticks by scene at all, so how you could get we were stationed in one basis.
So, that’s what we did and on the first visit we place our MPA and follow the technique that we just talked about on three months. We were already seen regeneration, and they listened completely heal, but unfortunately the patient came back with this situation. I truly believe that there was a problem: the communication between us, the general dentist and the patient.
It’s nothing very important that both the patient and the general dentist arm from that those buchanan’s.
Oh, that’s, not an ideal root canal isn’t going to have the appearance of a regular root canal and, as I’m telling you they in the referral, Dr Thought he was about root canal refer the patient somewhere else, and the patient came back with a completed root canal, but that’s completely against what we were looking for.
So, when we see this case, we got the pre-op and a three-month follow-up.
Were things uphill really good, and then we see the six-month follow-up. My face was as sad as my kid watching.
The last World Cup were spending in one a single game, and finally, we have an ortho case, courtesy of Dr Chance shot in Houston. This kid went to the Houston, dental school for authentic treatment and the shot caught this case after the treatment was done so because of his illusion. They wanted to subtract three molars, and we have a really close look at this case. You can see that the second maxillary molar on the right side has a little defect on the occlusal side and that’s how we typically see dance in the empty. It’s very important that we were very careful clinical examination, because if we’re gonna get to extract a tooth, we typically want to extract the one with pathology.
So unfortunately, there was no PA taken and Dr Cho got the case just like this. He was able to see signs dragon on the gum area when he got this case and referred the patient back to the endo department at Houston, so they were able to do a proper enumeration technique.
And here you can see how the crown it’s a little bit stained and that’s basically what we were talking about earlier, and they could prevent that step following what we said earlier.
So, let’s summarize, what we have to talk about regeneration techniques are gonna. Allow us to get fully development on a necrotic tooth with him at your apex and the way we’re gonna be able to do so.
It’s by doing a proper access cavity, that’s, in fact, a canal with our arrogance and then seal the coronal aspect with our composite and then on.
A second visit, we’re gonna be able to induce bleeding and that leading is going to be our matrix to get both tissue in the canal, and we’re gonna pack that were MTA to seal the canal coronary. I hope this lecture was informative to you. Please do not hesitate to contact me to my email per turn down picks at gmail.com. Thank you.