For an entire year, a 12-year-old boy lived with pain that came without warning. His lower left molar had a large cavity that had once kept him awake at night, while his gums repeatedly became swollen. Occasionally, salty fluid would drain from the area between the gum and tooth. Yet he had never received dental treatment.
When he finally visited the Pediatric Dentistry Clinic at Universitas Gadjah Mada, the examination revealed a serious condition: tooth 36, the lower left first molar, had pulpal necrosis, while its root apex, clinically referred to as the apical region, remained open. This meant that the tooth root had not completed its development before the pulp died.
This was where the dental team from the Department of Pediatric Dentistry, Faculty of Dentistry, UGM, made an unconventional decision: rather than extracting the tooth or simply closing the apex with an artificial material, they opted for revascularization, a regenerative endodontic approach that encourages the body to heal itself.
When Stem Cells Become the Key
Revascularization is not a new procedure, but its application to immature permanent molars with open apices continues to evolve. The basic principle is to utilize endogenous stem cells around the root apex to regenerate tissue and stimulate the continuation of root development.
drg. Putri Kusuma Wardani Mahendra, M.Kes., Sp.KGA., one of the specialists involved in the treatment, and her team performed the procedure over three main visits. During the first visit, they opened the pulp chamber roof, determined the working length using an apex locator, and irrigated the root canal with 1.5% NaOCl and sterile saline. A combination of three antibiotics—metronidazole, ciprofloxacin, and doxycycline—mixed with saline to form a paste was used as the intracanal medication.
Two weeks later came the most critical stage: induction of bleeding. A #15 K-file was inserted beyond the working length by 2–3 mm into the periapical tissue, inducing blood to enter the root canal. The resulting blood clot served as a natural scaffold, allowing stem cells from the periodontal ligament and bone marrow to migrate, proliferate, and differentiate into cementum-like tissue.
A collagen sponge was placed over the blood clot, followed by a 2–3 mm layer of white mineral trioxide aggregate (MTA). This was covered with glass ionomer cement before a temporary restoration was placed. During the third visit, one week later, the temporary restoration was replaced with a permanent composite resin restoration.
Thirteen Months, One Piece of Evidence
The success of revascularization does not become apparent within days. Instead, it gradually emerges through periodic radiographic examinations.
At the one-month follow-up, the apex had not yet closed, although the patient was symptom-free. By the third month, the root had begun to lengthen, although closure remained incomplete. At six months, the apex of the mesial root had closed, while the other two roots were still undergoing development.
Then, at month 13, a panoramic radiograph revealed a significant finding: all three root apices of tooth 36—the mesial, distolingual, and distobuccal roots—had completely closed. There was no pathological resorption. The crown-to-root ratio had improved. The tooth that had appeared almost “dead” a year earlier now had roots that were longer and thicker than before treatment.
“Revascularization treatment can be considered as one treatment option for teeth with pulpal necrosis and an open apical region. Operator skill, patient cooperation, and parental support contributed to the successful outcome in this case.”
The case report was published in the Jurnal Kedokteran Gigi Universitas Padjadjaran, Volume 36, Issue 3, December 2024. It was authored by Akbar Aulia Hidayat, together with drg. Putri Kusuma Wardani Mahendra, M.Kes., Sp.KGA., drg. Rinaldi Budi Utomo, and drg. Maulina Triani from Universitas Jenderal Soedirman.
Not Just a Technique, but a Collaboration
The authors openly noted an important limitation: a rubber dam was not available during the procedure. Tooth isolation relied solely on cotton rolls and assistance from a dental assistant to prevent saliva contamination. This acknowledgement reflects a real-world limitation in clinical facilities while also demonstrating that good outcomes can still be achieved through team expertise and strict adherence to procedural protocols.
The advantage of revascularization over conventional apexification lies in its ability to promote additional cementum formation and biologically strengthen the apical region rather than simply sealing it with an artificial material. However, the procedure takes longer, requires long-term monitoring, and depends heavily on patient compliance and parental support.
For the 12-year-old boy and his mother, who accompanied him to every visit for more than a year, the treatment was about more than saving a single molar. It was about choosing not to give up on a tooth that appeared to have already lost its chance—and giving the body an opportunity to demonstrate that regeneration was possible.
Source DOI: http://10.24198/jkg.v36i3.56148
Authors: Nanda Ayu, drg. Achmad Zam Zam Aghasy, M.Kes.
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