a procedure explaining the transplantation of decidous teeth is explained

2. Autologous transplantation of
deciduous tooth pulp into necrotic
young permanent teeth for pulp
regeneration in a dog model
Presented by:
Puja Mishra
Intern ,GSL Dental College

3. CONTENTS
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION
REFERENCES

4. INTRODUCTION

5. WHAT IS REGENERATIVE ENDODONTICS?
These procedures are designed to replace damaged structures,
including dentin and root structures as well as cells of pulp-
dentin complex
GOALS :-
1.PRIMARY GOAL : Elimination of symptoms and evidence
of bony healing
2.SECONDARY GOAL :- Increased root wall thickness or
increase in root length
3.TERTIARY GOAL :- Positive response to vitality test

6. TYPES OF REGENERATIVE PROCEDURES

8. How does regeneration occur?
• As bleeding occurs in root canal stem
cells from the apical papilla (SCAPs)
are introduced into the canal.
Release of growth factors from dentinal
walls
Initiates a series of biological events
that support the growth of hard and
connective tissues within the root canal
space
• Stem cells, signaling molecules (e.g.,
growth factors) and scaffolds are the
three critical components for
success of these procedures

9. PURPOSE OF THE STUDY
Despite reports of clinical and radiographic success, current regenerative endodontic
procedures are generally regarded as a reparative therapeutic strategy
o True regeneration is regarded as the development of de novo dental pulp tissue
in the root canal space ,recovery of regular homeostatic function
and immunocompetence
o True regeneration is also expected to include the establishment of biological
mechanisms at the dentin–pulp complex that would control the activity of
tertiary dentinogenesis, thus, preventing progressive pulp space obliteration

10. METHODOLOGY
• In the present study all experimental protocols were approved by the Animal
Research Ethics Committee and the Institutional Biosafety Committee of the
Affiliated Stomatological Hospital of Nanchang University .All animals
were handled in accordance Huang et al. 5095 with the guidelines established by
the Institutional Animal Care Committee..
• A total of six , 4 month-old male Beagle dogs (n = 6) were selected for the study
• In each animal, 10 teeth (four maxillary incisors and all six mandibular incisors)
were used in a split mouth design, such that 30 teeth served as the experimental
group; the contralateral teeth (n = 30) served as controls.
• Before the experiments, all teeth underwent radiographic examination to confirm
that they exhibited incomplete root formation and open apices

11. INTENTIONAL ESTABLISHMENT OF APICAL PERIODONTITIS
•The dogs were anesthetized ,local anesthesia was administered using
2% lidocaine
•Endodontic access cavities were prepared without isolation using
water-cooled sterile spherical and cone diamond burs
•The pulps were then extirpated, and the root canals were exposed to
the oral cavity for 2 weeks to allow for the establishment of microbial
biofilms and the development of inflammation. In immature teeth,
the development of apical periodontitis typically occurs within 15 to
25 days

12. ENDODONTIC TREATMENT
• A periapical radiograph was taken to confirm presence of periapical inflammation
• First, root canals were irrigated with 20 mL of 1.5% sodium hypochlorite,
followed by 20 mL of sterile saline; they were then dried with sterile paper points
and then canals were filled with a triple antibiotic paste.The access cavities were
temporarily sealed with conventional glass ionomer cement
• Four weeks later, the temporary cement was removed, and the canals were
irrigated with 20 mL of sterile saline, followed by 20 mL of 17% EDTA and a
brief final flush of sterile water. The root canals were dried with sterile paper
points.

13. Autologous transplantation of deciduous tooth
pulp in the experimental group
The deciduous cuspid was gently extracted under local anesthesia with
2% lidocaine
The crown was removed with a high-speed, water-cooled diamond disk
pulp tissue was then quickly removed using a small, sharp excavator with
minimal trauma.
Bleeding was then induced in permanent teeth by using a stainless steel
file to gently agitate apical tissue 1 to 2 mm beyond the apical level;
deciduous pulp tissues were immediately implanted into the root canal.

14. Continued..
The transplanted deciduous pulp was allowed to
remain in contact with blood for 1 minute without
interruption
A thin layer of MTA was placed over the blood
clot and the remaining cavity space was filled with
GIC
One week later, the cavity space was filled with a
resin composite by a total-etch adhesive protocol
using Single Bond (3M/ESPE)

15. TRADITIONAL REVASCULARIZATION OF CONTROL
TEETH

16. Postoperative procedures, histological and
immunohistochemical analysis
• The animals were monitored closely throughout the experiments,
and no unusual behaviors were observed, including changes to
food intake. However, at the end of the experiment, 11 teeth were
excluded from the study due to crown fractures, such that 25 teeth
remained in the experimental group and 24 remained in the control
group.
• Radiographic examinations were carried out immediately, as well as at
3 and 6 months post-treatment, to evaluate continued periapical
healing, apical closure, and thickening of the root canal wall.

17. HISTOLOGICAL ANALYSIS
• At the end of the experiments (6 months post-treatment), all animals were
euthanized by an intravenous overdose of sodium pentobarbital. Block sections of
the jaws were dissected ,tissue processing was done followed by H&E staining
• The following histopathological parameters were evaluated:
1. The presence or absence of substantial new hard tissue
2. The presence or absence of healing of periapical inflammation that resulted in
reduction of radiolucency
3. The presence or absence of continued thickening of the root canal wall
4. The presence or absence of apical foramen closure and reduction in apical
diameter

18. IMMUNOHISTOCHEMICAL ANALYSIS
• To evaluate angiogenesis, neurogenesis, and repair and/or regeneration of the pulp-
dentin complex following autologous pulp transplant, immunohistochemical
analyses were also performed
• Tissue sections were first subjected to antigen retrieval with proteinase K (30
mg/ml), and then incubated with 0.3% hydrogen peroxide in methanol for 30
minutes
• To evaluate angiogenesis the sections were incubated with
rabbit anti-CD3 an immunomarker for
vascularization
• To evaluate neurogenesis rabbit anti - Nestin ,a biomarker for nerve fibers

19. • To evaluate regeneration of rabbit anti -dentin
pulp-dentin complex sialoprotein(DSP)
• For negative controls, regular rabbit serum was used in place
of the indicated antibodies. After visualization of
immunoreactivity sections were counterstained with
hematoxylin and viewed in microscope

20. RESULTS OF RADIOGRAPHIC ANALYSIS
• Radiographic examinations were carried out
immediately, as well as at 3 and 6 months post-
treatment, to evaluate continued periapical healing,
apical closure, and thickening of the root canal wall
• FIG A: Shows apical periodontitis model established
after 2 weeks and the unsealed access cavities
• FIG B: model at 3 months postoperatively. At this
stage, healing of periapical inflammation is indicated
by reduction of radiolucency, narrowing of the apical
foramen, thickening of root canal walls
• FIG C :shows the model at 6 months postoperatively.
At this stage, complete apical closure and advanced
root growth are visible. Periapical radiolucency on the
left maxillary central incisor indicates treatment failure
(black arrow)

21. •In most parameters evaluated, there were no significant differences, there was
a significant reduction in apical diameter between the experimental group and the
control group (P ¼ 0.03, Table 1)​

22. HISTOLOGICAL AND IMMUNOHISTOCHEMICALANALYSIS
EXPERIMENTAL GROUP CONTROL GROUP
HISTOLOGICAL ANALYSIS  New dentin-like tissue was
seen along the canal walls
 Deposition of cementum like
tissue which was present in a
scattered fashion within bone
fossae .
IMMUNOHISTOLOGICAL
ANALYSIS
(anti-
DSP immunohistochemistry)
 More number of odontoblasts
and blood vessels
 Fibrous tissue with more number
of evenly arranged cells
 Only few odontoblasts and
newly formed blood vessels
were seen
 Fewer cells were seen

23. Teeth that received transplanted deciduous pulp (panels A, C, and
D) show generation of dentin-like structures, while teeth that
underwent traditional revascularization (B) show mostly
cementum-like repair tissue
Panel A is a representative image of central root tissues, showing
dentin-like tissue formation with angular orientation of dentinal
tubules (a) over existing dentin (b), as well as connective tissue (c)
rich in blood vessels (d) and fibers
Panel B is a representative image of central root tissues, showing
deposition of cementum-like (cm) repair tissue along the root
canal wall and within the root space, incorporating bone lacunae
Panel C is a representative image of the apical one-third region,
showing odontoblast cells (ob) and connective tissue rich in blood
vessels (d) and fibers
Panel D is an enlargement of the region within the black circle in
panel C, showing odontoblast cells (ob) and connective tissue (400

24. • Panels A and B are representative
images that show localization of
CD31, an immunomarker for
vascularization: A shows canal
tissue rich in blood vessels
and arrows in panel B indicate a
blood vessel.
• Panel C is a representative image
that shows localization of dentin
sialoprotein (DSP) in odontoblast
cells ; and arrows indicate
odontoblast cells.

25. • Panels E–H are representative images
that show localization of anti-Nestin
antibody binding to nerve fibers and
some transformed cells, such as pulp
cells.
• Panel E shows odontoblast cells and
connective tissue rich in blood vessels
and fibers and arrows in F indicate
blood vessels and fibers.
• Panel G shows odontoblast cells and
arrows in H indicate odontoblast cells.

26. DISCUSSION
• Deciduous tooth pulp contains a large number of deciduous pulp
stem cells, which may serve as a good source of cells for pulp
regeneration
• Although ,newly formed mineralized tissue was observed in both
the groups, the control group showed cementum like deposition
which indicated repair
• Few recent studies showed that soft tissues formed in the canals
of revascularized teeth were more similar to periodontal ligament
than to normal pulp.

27. • Conversely, the mineralized tissue that developed in the experimental group
closely resembled dentin, as it contained dentinal tubules; soft tissues
within the root canals were rich in blood vessels and fibers.
• In addition, there were significant differences in apical diameter reduction
between the experimental group and the control group. These differences
may be partly attributed to the different types of stem cells used in the two
groups
• Specifically, stem cells used in the control group were mainly derived from
SCAPs, whereas those used in the experimental group were mostly from
exfoliated deciduous teeth that can differentiate into odontoblast-like cells
and secrete dentin matrix, forming odontogenic dentin pulplike tissue,
odontoblast-like cells, and bone formation in vivo

28. • For an regenerative endodontic procedure to be
successful scaffold plays an important role
• Autologous deciduous dental pulp tissue does not
require processing and can readily serve as a
biological scaffold that contains multiple inherent
growth factors
• These growth factors attract stem cells and
promote stem cell proliferation by promoting
angiogenesis in the initial stages of healing thus
establishing vasculature to ensure sufficient
nutrient supply for tissue regeneration
• In this study the stem cells were placed in an
environment similar to that of their physiologic
environment which might have aided in their
proliferation
1. Be biocompatible
2. Facilitate the proliferation
of the stem cells
3.Improved and faster tissue
development
4.Contain nutrient to provide
cell survival and growth

29. • In deciduous pulp implantation, the implanted tissue is already vital and
initiates a series of biological processes when it comes into contact with the
induced blood; because of these processes, SCAPs and stem cells from
exfoliated deciduous teeth are activated. Stem cells from exfoliated deciduous
teeth are capable of extensive proliferation and multipotent differentiation.
• Additionally, autologous deciduous pulp provides a matching donor with no
risk of communicable disease, counteractive immune reactions, or tissue
rejection, as well as no need for immunosuppression be have contributed to
the regeneration seen in the study

30. • Dogs share many similarities with humans
in terms of tooth structure and
pathophysiological responses.
• Using a dog model, this study has
provided evidence that implantation of
deciduous tooth pulp tissue can yield
favorable clinical, radiographic, and
histological outcomes.
• These results suggest that autologous
transplantation of deciduous tooth pulp
can be used as a new and effective
biologically based treatment approach to
facilitate dental pulp regeneration
in necrotic young permanent teeth
CONCLUSION

31. • Based on this study, a new study was conducted on five previously traumatized incisors of 8 to 11 year old children .
• The patients were treated with a endodontic protocol that used 2.5% NaOCl irrigation and placement of
calcium hydroxide dressing in the first visit.
• After 4 weeks, the intracanal medication was removed, and the whole pulp tissue harvested from the
neighboring maxillary deciduous canine was transplanted into the disinfected root canal without induced apical bleeding.
• Following placement of a MTA coronal barrier, the access cavities were restored with acid-etch resin composite.
The root canals of donor primary canines were filled with calcium hydroxide-iodoform paste and were restored as with
the permanent incisors.
Zafer C. Cehreli, Gizem Erbas Unverdi, Elif Ballikaya,
Deciduous Tooth Pulp Auto transplantation for the Regenerative Endodontic Treatment of Permanent Teeth With Pulp
Necrosis: A Case Series,
Journal of Endodontics,
2022

32. Three patients were followed-
up for 24 months, and 1
patient for 12 months. All
teeth demonstrated
radiographic evidence of
complete periapical healing,
slight increase in
dentinal wall thickness, and
continued apical closure in
the absence of clinical
symptoms. A
positive response to cold
test was obtained in 1 incisor
at 12 months and 2 at
24 months.
RESULTS
Based on 12- and 24-month
clinical and radiographic
findings, the present
cases demonstrate a
favorable outcome of a
regenerative endodontic
protocol using
deciduous pulp auto
transplantation in young
permanent incisors
with pulp necrosis
CONCLUSION

33. REFERENCES
• Yan Huang , Xiaoying Tang , Zafer C. Cehreli, Xiaoyun Dai, Jiangjingjun
Xu1 and Hongshui Zhu, Autologous transplantation of deciduous tooth
pulp into necrotic young permanent teeth for pulp regeneration in a dog
model ,Journal of international medical research,2019,vol 47.
• Franklin Garcia-Godoy , Peter E. Murray, Journal of Dental
traumatology2012,vol 28
• Grossmans Endodontic practice 8th edition

34. GUIDED BY:
Dr. Veena Arali
Head of department,
Department of
Pediatric Dentistry
GSL Dental college
Dr. Harika .R
Reader
Department
of Pediatric Dentistry
GSL Dental college
Dr. Charan Teja. V
Reader
Department
of Pediatric Dentistry
GSL Dental college