Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial)

Hala Ahmed Tawfeek; Adel Abdel-Azim El-Bardissy; Mohammed Abou El-Yazeed; Randa Youssef; Ahmed Mohamed Abd Alsamad

doi:10.1038/s41405-023-00143-x

Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial)

Tawfeek, Hala Ahmed; El-Bardissy, Adel Abdel-Azim; Abou El-Yazeed, Mohammed; Youssef, Randa; Abd Alsamad, Ahmed Mohamed 2023-04-28 00:00:00 www.nature.com/bdjopen ARTICLE OPEN Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial) 1✉ 2 3 2 Hala Ahmed Tawfeek , Adel Abdel-Azim El-Bardissy , Mohammed Abou El-Yazeed , Randa Youssef and Ahmed Mohamed Abd Alsamad © The Author(s) 2023 OBJECTIVE: To evaluate and compare clinically and radiographically the effect of using two different coronal plug materials (NeoMTA versus Conventional White mineral trioxide aggregate) in revascularization of non-vital immature permanent anterior teeth, with special reference to the assessment and evaluation of discoloration potential over a period of one year. METHODS: Revascularization procedure was performed in (30) immature permanent non-vital anterior teeth which were randomly allocated to two equal groups (n = 15). NeoMTA was used as coronal plug material in the Experimental Group (N), while conventional White mineral trioxide aggregate (WMTA) was used as a coronal plug material in the Control Group (W). All treated teeth were evaluated clinically at 1 week, 1, 3, and 12 months and radiographically at 12 months. RESULTS: The overall clinical and radiographic success rate of Groups (N) and (W) at the end of the 12-month follow-up period was 100%. The discoloration was detected in a single tooth (9.1%) in Group (N) and three teeth (27.3%) in Group (W) but the difference between groups was not statistically signiﬁcant. CONCLUSIONS: Both NeoMTA and conventional WMTA were successful coronal plug materials in the revascularization of non-vital immature permanent teeth achieving a high level of clinical and radiographic success. NeoMTA is a promising coronal plug material that can be used for revascularization procedures in the esthetic zone as it showed less discoloration potential compared with conventional WMTA, however, there was no statistically signiﬁcant difference between both materials. BDJ Open (2023) 9:17 ; https://doi.org/10.1038/s41405-023-00143-x INTRODUCTION Revascularization treatment is based on the postulation that is Pulp necrosis of immature permanent teeth is considered a critical creating an environment free of microorganisms with a proper condition because it leads to the arrest of root development and bacterial-tight seal in the presence of an appropriate three- incomplete dentin deposition leaving a weak fragile root that is dimensional scaffold, stem/progenitor cells inside the root canal; more liable to fracture, it will also lead to a poor crown/root ratio stimulates tissue repair in nonvital immature permanent teeth [1, 3, 6]. with a possible periodontal breakdown [1–3]. Mineral trioxide aggregate (MTA) has been widely used in Several techniques have been used for the management of non- revascularization procedures for coronal sealing in more than 85% vital immature permanent teeth including calcium hydroxide of studies because of its biocompatibility, good sealing properties, apexiﬁcation and apical plug technique. Although these techniques and marginal adaptation. However, its poor handling character- were successful in achieving apical closure and healing of the istics and potential coronal discoloration effects are the major periapical pathosis, they do not contribute to any quantitative or disadvantages of using white mineral trioxide aggregate (WMTA) qualitative increase in root dimensions since a hard tissue barrier [7, 8]. formation only occurs apically without further root development [2]. The NeoMTA (NuSmile, Huston, USA) is pure MTA that is Revascularization is a regenerative endodontic procedure (REP) marketed as a cost-effective MTA intended to be used for pediatric that stimulates the continuation of root development. It is pulp therapy as it has fast setting time, easy handling and most considered a valuable treatment as it strengthens the root walls important modiﬁcation is its non-staining formulation. Tantalum by stimulating the deposition of hard tissues and promoting the oxide (Ta O ) has been added to NeoMTA as a radiopacifying 2 5 development of normal apical morphology [4, 5]. agent instead of bismuth oxide (Bi O ) which has been linked 2 3 Pediatric Dentistry, Orthodontics and Pediatric Dentistry Department, Oral and Dental Research Institute, National Research Centre, Giza, Egypt and Phd student in Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Cairo University, Giza, Egypt. Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Cairo University, Giza, 3 4 Egypt. Pediatric Dentistry, Orthodontics and Pediatric Dentistry Department, Oral and Dental Research Institute, National Research Centre, Giza, Egypt. Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University, Giza, Egypt. email: at.mohamed@nrc.sci.eg Received: 12 January 2023 Revised: 7 March 2023 Accepted: 23 March 2023 1234567890();,: H.A. Tawfeek et al. mainly to the cause of discoloration in conventional mineral trioxide aggregate [8, 9]. Revascularization of immature permanent teeth has become an important part of endodontic treatment modalities. Despite its high success rate clinically and radiographically, many studies have reported that discoloration is a signiﬁcant esthetic concern following revascularization procedure as appearance and pleasing esthetics are patient-centered outcomes [7]. Most currently available clinical trials mainly focus on clinical and radiographic outcomes of materials in addition to reporting their discoloration potential only in binary ways. Available data concerning the quantitative assessment of discoloration of new materials are from in-vitro studies bear in mind the difference in a clinical scenario than under controlled in-vitro conditions. So, this study aimed to evaluate clinically and radiographically the effect of using two types of Fig. 1 Radiographic stent (acrylic bite block) and shadow of the coronal plug materials in the revascularization of non-vital immature embedded stainless-steel wire appearing. permanent anterior teeth with special reference to assessment and evaluation of discoloration potential over a period of one year. SUBJECTS AND METHODS The Research Ethics Committee, Faculty of Dentistry, Cairo University approved the protocol for this parallel, double-blinded, randomized controlled trial with a 1:1 allocation ratio with (reference no.18/7/52). The study has been registered on Clinicaltrials.gov with identiﬁcation number: NCT03545139, under the title Clinical & Radiographic Evaluation of NeoMTA Versus Conventional White MTA in Revascularization of Non- Vital Immature Permanent Teeth. The trial was conducted from September 2019 to January 2021. Sample size determination Sample size determination was done before the study using R statistical package version 3.3.1. The T-test power calculation was used to detect the proper sample size based on the results of Lenherr et al. [10]. A total sample size of 22 (teeth) was found to be adequate to detect a mean difference in color change between study groups of 3.5 points (SD = ± 2.44) with a power of 90% and a two-sided signiﬁcance level of 5%; with equal allocation to two arms (11 teeth in each group). To compensate for Fig. 2 Individualized extension cone paralleling index. 30% non-response rate or possible patient attrition, the sample was increased to a total size of 30 (teeth) that were divided into 2 groups. Endodontology for revitalization’s pre-operative diagnostic procedures [1]. – Conventional pre-operative periapical radiograph was taken. Study setting – Detailed procedures, beneﬁts, and expected harms were discussed – A total of 30 non-vital immature permanent anterior teeth in 25 with the child’s legal guardian, then informed consent was obtained. children were enrolled in this study from the outpatient clinic of the – Preparation for digital radiographic procedures and construction of Pediatric Dentistry Department, Faculty of Dentistry, Cairo University. radiographic stent was done to perform an individualized Extension – The procedures were carried out by the main investigator for all patients. Cone Paralleling (XCP) index for each patient according to Aly et al. [2]. A radio-opaque object of known dimension (5 mm stainless steel wire) was embedded in the acrylic stent before setting [11]as shown in Figs. 1, 2. Eligibility criteria Inclusion criteria. Randomization and allocation concealment – 8–15 years old children. The 30 permanent immature teeth were randomly assigned by simple – Free from any systemic diseases. randomization procedure into two equal groups, Experimental Group (N): – Upper traumatized permanent anterior teeth with non-vital pulp and TM 15 teeth treated with NeoMTA (NuSmile Neo MTA ) and Control Group immature root apex. (W): 15 teeth treated with Conventional WMTA (White Angelus MTA) using – Pulp space not needed for post and core. shufﬂed closed white opaque envelopes picked by a patient at the second appointment just before placement of the coronal plug step. Exclusion criteria. Blinding – Poor oral hygiene. – The participants and legal guardians were blinded. – Teeth with root resorption, luxation injuries, and root fracture. – Radiographic assessor, one of the clinical assessors for the color – Teeth with severe discoloration/ unacceptable color difference change to avoid detection bias, and the statistician were blinded to between affected tooth and contralateral tooth (ΔE ≥ 5). avoid reporting bias. Pre-operative protocol Intraoperative procedures – Personal, medical, dental, trauma history, and clinical examination Treatment of the selected teeth was performed according to AAE [12] were attained based on the checklist of the European Society of clinical considerations for a regenerative procedure, same procedures were BDJ Open (2023) 9:17 H.A. Tawfeek et al. BDJ Open (2023) 9:17 Table 1. Participant timeline for enrollment, treatment procedures and follow up. Study period Enrolment Treatment procedures Follow up Close out Time point (Resistant cases) T T 1st appointment 2nd app 4 w 4w T1 1w T2 1m 33m T46m x 12m (T ) Enrolment Eligibility screen X Verbal interview X Diagnostic chart X Clinical examination X Preoperative conventional periapical X X-ray Preoperative photograph X Preoperative color assessment of X affected tooth Informed consent X Allocation X Impression for Radiographic stent X Intervention Access cavity X Minimal mechanical debridement X Irrigation X Antimicrobial dressing X Removal of antimicrobial dressing x X Inducing bleeding X X Placement of collagen plug X X Placement of coronal plug material XX Access cavity sealing X X Composite buildup X Assessment Color assessment XX x x X X x (baseline) then follow ups Clinical assessment X X X X X X x Immediate post operative Digital XX X x Radiograph and follow ups H.A. Tawfeek et al. applied to all teeth in the study the only difference was the coronal plug were asked about pain, and change in color if present. Parents were material used. taught how to examine visually the vestibule. Moreover, parents were requested to send an intra-oral photo if possible. All the data that were collected during this period were just to check on patients but were First appointment for revascularization procedure. Each tooth was locally not used for statistical analysis. anesthetized using topical anesthesia gel benzocaine 20% followed by – Composite build-up (3 M, Filtek, Z350, United Kingdom) was done to all labial inﬁltration using Articaine HCL 4% with 1:100,000 epinephrine then fractured teeth after the end of 12 month follow-up period to eliminate isolated with a rubber dam. A conventional access cavity was done then the masking effect of restoration on evaluation of discoloration. the working length was determined radiographically. Passive pressure irrigation using 1.5% sodium hypochlorite (NaOCl) (20 mL/canal, 5 min) In the follow-up visit the treated teeth were evaluated for: with a side vent needle placed 1–2 mm from the apex, then sterile Clinical parameters: physiological saline (5 mL), followed by 17% Ethylenediaminetetraacetic acid (EDTA) (20 mL/canal, 5 min). Canal dryness was performed using suitable size paper points then placement of intracanal medication (double a. Pain on biting: reported by asking the patient about the presence of antibiotic paste) prepared from equal amounts of Ciproﬂoxacin 500 mg pain while biting (Yes/No). and Metronidazole 500 mg with a ratio of 1:1. The mix was delivered into b. Pain on percussion: detected by tapping the tooth with the back of the canal using a disposable plastic syringe having plastic tips adjusted to an autoclavable mirror. be 2 mm shorter than the working length. The excess paste was removed, c. Presence of swelling, sinus, or ﬁstula: checked by visual examination and the access cavity was sealed with dry cotton and 3–4 mm of light- and palpation of the labial vestibule and the palatal area related to cured resin-modiﬁed glass ionomer (RMGI) (Riva, SDI, Australia) then the every affected tooth. patient was dismissed for 4 weeks. d. Mobility: was examined using the back of 2 autoclavable mirrors. The unit of measuring these parameters was binary (present/absent). Second appointment: (4 weeks after the First appointment). After 4 weeks, Discoloration: the response to the initial treatment done at the ﬁrst appointment was assessed. a. Parental reporting of discoloration: by verbally asking parents whether they noticed visually the presence/absence of change in Criteria of clinical success or failure of the ﬁrst appointment tooth color. according to the AAE [12]: Complete resolution of signs and b. Visual assessment of discoloration by two assessors (the main symptoms which include pain, swelling, sinus, or ﬁstula was considered investigator and another clinical assessor) reported the presence/ success of the ﬁrst appointment. absence of tooth color change (Binary outcome) detected by visual examination. Tooth color assessment: 1. Tooth color baseline T was recorded for the affected tooth at the – Cohen’s kappa value was used to assess the agreement between the 2 beginning of the second appointment using VITA Easyshade V assessors. digital spectrophotometer, three measurements were recorded then the mean color was calculated. 2. Intraoral photographs were captured for documentation using ﬁxed c. Quantitative assessment of color change: settings of the camera with no ﬂash [13]. The spectrophotometer measured the color of teeth based on the Commission Internationale de I’Eclairage’s CIELAB color space system. The Operating procedures: Each tooth was locally anesthetized using L* a* b* system allows color speciﬁcation within a three-dimensional space topical gel and labial inﬁltration using 3% mepivacaine without where: vasoconstrictor. The temporary dressing was removed after isolation by rubber dam then irrigation with 17% (EDTA) (20 mL/canal, 5 min) followed a. The L* axis represents the degree of lightness within a tooth and by canal dryness. Bleeding was obtained by over-instrumenting and ranges from 0 (black) to 100 (white). rotating a pre-curved K-ﬁle at 2 mm past the canal to have the entire canal b. The a* plane represents the degree of green–red within a tooth, a* ﬁlled with blood. A tight cotton pellet slightly wetted with sterile saline was values ranges from red (+80a*) to green (−80a*). inserted and left for 10–15 min to allow the formation of a clot then c. The b* plane represents the degree of blue–yellow within the tooth cleaning of any blood remnants on the walls of the cavity was done using and b* values range from yellow (+80b*) to blue (−80b*). a bond brush. A resorbable collagen matrix Colla-plug™ (Zimmer Dental Inc. Aston Avenue Carlsbad, CA, USA) was placed over the clot followed by – Three measurements were recorded for each follow-up then the mean placement of the coronal plug material according to the tooth allocated in color was calculated. which group, either NeoMTA (NuSmile Neo MTA™.) or conventional WMTA – The change in tooth color was calculated by monitoring changes in ΔL, (White Angelus MTA. Angelus Indústria de Produtos Odontológicos. Waldir Δ a, Δ b by subtracting the baseline measurements from the follow-up Landgraf Street- Londrina- Brazil) forming about 3 mm thickness just measurements. underneath the cementoenamel junction (CEJ). Excess material on the – Delta E (ΔE) is the total color difference or the distance between two cavity wall was removed, then a conventional periapical radiograph was colors, (ΔE) was calculated according to the following equation: taken to double-check the proper position of the coronal plug in relation 2 2 2 ½ ΔE = ([L _L ] + [a _a ] + [b _b ] ) [13, 14]. to CEJ. Once the material became ﬁrm within 10–15 min, RMGI followed by x 0 x 0 x 0 – The proposed limit for color difference adopted in this study was set at composite ﬁlling (3 M, Filtek, Z350, United Kingdom) was placed. 3.7 ΔΕ units (perceptibility threshold) which means how much color Immediate postoperative (baseline) digital radiograph was taken at the change is considered perceptible, differences beyond this limit were end of the second appointment using a Digital x-ray machine (Minray, considered clinically perceptible [14, 15]. Soredex, Tuusula); using a standardized paralleling technique by the (XCP) alignment system with the radiographic stent and the large 3 × 4 cm Radiographic Parameters: phosphor storage plates (PSPs) imaging plate (Soredex DIGORA®, Finland). The DIGORA Optime scanner scanned imaging plates. a. Presence of external or internal root resorption. – All patients were planned to be recalled for clinical follow-up after b. Assessment of periapical area: presence or absence of radiographic 1 week, 1 month, 3 months, 6 months, and 12 months while signs of infection. radiographic follow-up was planned to be at 6 months and 12 months c. Root lengthening: as shown in Table 1, but due to the Covid-19 lockdown, a modiﬁed follow up was done as all patients were not able to attend the six Root length was measured on the Digora software and the increase in months recall visit. Consequently, the following measures were done root length and percentage of change in root length were calculated using to assure the patients and their parents. Through a phone call, parents equations according to Aly et al. [2]. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 3 Flow Chart of the study population through the study. RESULTS Table 2. Age and gender distribution among study between two During the follow-up period, four cases (26.7%) dropped out from groups. each group and were excluded from the data analysis. Twenty children with 22 teeth completed the 12 months study period. The Groups Mean age Gender % ﬂow of the patients throughout the study is presented in Fig. 3. Male Female Regarding the demographic data age and gender distribution Group (N) 9.07 ± 0.96 66.7% 33.3% among study subjects, were presented in Table 2 with no statistically signiﬁcant difference within both groups (p-value= Group (W) 9.43 ± 1.55 53.3% 46.7% 0.443 and 0.771 respectively). Regarding the evaluation of clinical outcomes, all teeth showed Increase in length = 12 m follow-up root length—immediate post- normal clinical ﬁndings, there was a complete absence of signs operative root length and symptoms such as pain on biting, pain on percussion, Percentage of change in length = 12 m follow-up root length—immediate swelling, sinus/ﬁstula, and mobility in both groups during all post-operative root length /immediate post-operative root length x 100. follow-ups so both groups were (100%) clinically successful with no statistically signiﬁcant difference between groups. Concerning evaluation of discoloration, none of the parents Statistical analysis The results of the present study were interpreted using per-protocol reported discoloration at the 1-week follow-up, at 1 month only analysis. one parent in Group (N) reported the presence of discoloration in Categorical data presented as frequencies and percentages were one tooth (9.1%) and two parents in Group (W) reported analyzed using the Chi-square test. Quantitative data were explored for discoloration in 2 teeth (18.2%), at 3 and 12 months follow up normality using Kolmogorov-Smirnov and Shapiro-Wilk tests and were only one parent in Group (N) reported discoloration at one tooth found to follow the normal distribution, so they were presented as mean (9.1%) and three parents in Group (W) reported discoloration in 3 and standard deviation (SD) and were analyzed using the independent teeth (27.3%) and the difference between groups was not t-test with the signiﬁcance level set at p ≤ 0.05 for all tests. Cohen’s kappa statistically signiﬁcant (p value = 0.269). value was used to assess the agreement between raters. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Table 3. Mean and Standard deviation (SD) values for ΔL, Δa, Δb in both groups. Parameter Interval (Mean ± SD) p-value Group (N) Group (W) ΔL 1 week- Baseline −0.50 ± 1.65 −1.29 ± 2.29 0.365 ns 1 month- Baseline −0.69 ± 1.78 −2.04 ± 2.24 0.134 ns 3 months- Baseline −1.05 ± 2.80 −2.20 ± 2.45 0.317 ns 12 months-Baseline −1.01 ± 3.17 −2.80 ± 2.77 0.173 ns Δa 1 week- Baseline 0.07 ± 0.34 −0.28 ± 0.48 0.070 ns 1 month- Baseline 0.12 ± 0.40 −0.27 ± 0.42 0.037* 3 months- Baseline 0.18 ± 0.28 −0.28 ± 0.44 0.011* 12 months- Baseline 0.20 ± 0.40 −0.23 ± 0.52 0.041* Δb 1 week- Baseline −0.20 ± 1.10 −0.69 ± 1.05 0.294 ns 1 month- Baseline −0.56 ± 1.55 −0.69 ± 1.07 0.813 ns 3 months- Baseline −0.45 ± 1.71 −0.71 ± 1.36 0.693 ns 12 months- Baseline −0.40 ± 2.20 −0.71 ± 1.67 0.713 ns *signiﬁcant (p ≤ 0.05) ns; non-signiﬁcant (p > 0.05). Fig. 4 Line chart showing mean values for ΔE in both groups. The discoloration was assessed visually by two clinicians and The mean Δb value of Group (W) was more than Group (N), in a there was an excellent agreement between both ratings of the direction indicating a reduction of yellow color thus an increasing clinical data (k = 1, p < 0.001). At 1 week no discoloration was change towards the blue direction with no signiﬁcant difference detected in Group (N), while one tooth (9.1%) showed discolora- between groups. Mean and standard deviation values for ΔL, Δa, tion in Group (W). At 1 month, discoloration was detected in one Δb are presented in Table 3. tooth (9.1%) in Group (N) and three teeth (27.3%) in Group (W). At The mean ΔE value at 12 months in the WMTA group was 3, 12 months follow-ups discoloration was detected in a single (ΔE = 3.64 ± 2.31) and NeoMTA group was (ΔE = 2.99 ± 2.56). No case (9.1%) in Group (N) and three cases (27.3%) in Group (W), and statistically signiﬁcant difference between both materials during the difference between groups was not statistically signiﬁcant (p the 12 months (p value = 0.535). Mean values for ΔE are presented value = 0.269). in Fig. 4. Clinical photographs showing the evaluation of The change in color between baseline and 12 months was discoloration in Group (N) and (W), Figs. 5 and 6. quantiﬁed for each tooth by measuring the CIE L*a*b* values and The mean and standard deviation values for initial root length calculation of ΔE. in mm were 11.694 (± 1.644) mm for Group (N) and At the end of 12 months, it was found that the mean ΔL value of 12.654(± 1.449) mm in Group (W). There was no signiﬁcant Group (W) was more than Group (N), in a direction indicating difference in mean initial root length in both groups (p- decreased luminosity with no signiﬁcant difference between value = 0.162). groups. Continued root lengthening was observed in this study, the The mean Δa value at the end of 12 months showed that Group mean increase in root length in mm and percentage between (N) remained in the red values direction, while Group (W) showed 12 months follow-up and pre-operative root length in Group (N) a reduction in redness thus an increasing change towards the was 1.03 (± 0.97) mm, 8.52(± 3.33)% and in Group (W) was 1.04 green direction. The alterations observed in the WMTA group (± 0.86) mm, 8.64(± 4.30)% with no signiﬁcant difference between were signiﬁcantly greater compared with the other group. both groups. Mean and Standard deviation (SD) values are shown BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 5 Clinical photographs of fractured upper left central incisor which was the single case that showed clinical discoloration in Group (N), change in color started to show at the 1 month follow up. a Baseline clinical photograph of upper left central incisor at second appointment, b Clinical photograph at 1 week follow up without discoloration, c Clinical photograph at 1 month follow-up showing shadow of cervical crown discoloration, d Clinical photograph at 3 months follow-up showing cervical crown discoloration, e Clinical photograph at 12 months follow-up showing cervical crown discoloration. f Clinical photograph showing composite buildup. in Table 4. Digital radiographs showing an increase in root length apical papilla (SCAPs) and Hertwig epithelial root sheath (HERS) in Group (N) and (W), Figs. 7, 8. might be damaged [20]. Regarding the radiographic evaluation, all teeth in both Groups The exclusion of cases with unacceptable discoloration (N) and (W) were free of internal and external root resorption also compared with the contralateral tooth was done in order not to there was a complete absence of any radiographic signs of affect the evaluation of discoloration that might occur. The infection, accordingly the overall clinical and radiographic success unacceptable discoloration limit for exclusion of cases (ΔE more rate was 100% for both Groups (N) and (W). than 5) was determined by following the intraoral perceptibility and acceptability tolerances for color mismatch reported in the literature, a difference of ΔE starting from 5.5 to 6.8 was required DISCUSSION for dentists to ﬁnd the color mismatch sufﬁciently unacceptable to Revascularization of immature permanent teeth has become an suggest further treatment to improve it [21, 22]. important part of endodontic treatment modalities. Despite its The radiographic standardization was done by the construction high success rate clinically and radiographically, the concerns of a radiographic stent for bite registration to facilitate consistent about post-revascularization tooth discoloration were increasing positioning of the ﬁlm. Moreover, (XCP) alignment system was [7]. This outcome is unfavorable and signiﬁcantly impacts the used for a paralleling technique to allow comparisons of the quality of life in children negatively, therefore materials with digital radiographs [2, 23]. A radio-opaque marker of known the lowest possible staining potential should be considered in the dimension was embedded in the acrylic resin stent to help in the esthetic zone. determination and compensation of the magniﬁcation factor of The cause of post-revascularization discoloration is still deba- the radiographic images thus minimizing errors in the measure- table, but most ﬁngers point to the presence of bismuth oxide in ment of root length [11]. the conventional WMTA and its reaction with dental tissues, blood Treatment procedures of the selected teeth were performed products, and irrigants used in revascularization procedures according to AAE [12] clinical considerations for a regenerative [16,17]. Although WMTA was developed to overcome tooth procedure. Lower concentrations of NaOCl (1.5 % concentration) discoloration encountered with the use of the Grey mineral were advised and recommended by AAE [12] to keep the balance trioxide aggregate (GMTA), several in vitro studies had reported between sufﬁcient disinfection and preservation of SCAPs. Since it evidence of tooth discoloration [14, 18]. has been proven that using higher concentrations of NaOCl has a Accordingly, NeoMTA was suggested as coronal plug material in profound negative effect on the survival and differentiation of the intervention group, since it is a pure WMTA that is marketed SCAPs or expression of proteins of the dentin matrix that are by having a new non-staining formulation, due to replacing the involved in promoting tissue regeneration [24–26]. radiopaciﬁer (Bi O ) with (Ta O ), moreover, it has been reported It was recommended by the AAE [12] to set the second 2 3 2 5 that it has better handling characteristics and forms putty appointment within 1–4 weeks from the ﬁrst appointment consistency upon mixing [8]. Therefore, it was recommended to according to the assessment of the response to initial treatment, investigate the material performance in various clinical Since it was a must to standardize the time of the second applications. appointment for all patients to limit any variables the maximum The inclusion and exclusion criteria of the present study have time interval given by the AAE was set for all patients to be able to been determined according to the AAE [12] clinical considerations take a decision either to proceed for a second visit or consider for regenerative procedures. Teeth showing severe coronal additional treatment time with antimicrobial. fracture were excluded from the study because the pulp space The baseline color assessment was done at the beginning of the won’t be available for post retention and the VITA Easyshade second appointment before the teeth are exposed to dehydration probe’s diameter is 5 mm so, at least 5 mm of intact cervical as recommended by Burki et al. [27] since most dental procedures enamel was needed to evaluate color changes [19]. Teeth with lead to teeth dehydration which alters tooth shade and shows luxation injuries were excluded since the stem cells from the perceivable color change causing errors in color assessment. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 6 Clinical photographs of 9 years old child presented with traumatized upper left central incisor enrolled in Group (W) showing clinical change in color that started to show at the 1 month follow up. a Baseline clinical photograph at second appointment, b Clinical photograph at 1 week follow up without discoloration, c Clinical photograph at 1 month follow-up showing shadow of cervical crown discoloration, d Clinical photograph at 3 months follow-up showing cervical crown discoloration, e Clinical photograph at 12 months follow- up showing cervical crown discoloration. f Clinical photograph showing composite buildup. parents (27.3%) in Group (W) reported discoloration at the end of Table 4. Mean and Standard deviation (SD) values for change in root 12 months. This result was not in line with Nazzal et al. [33] who length in (mm) and (%) in both groups. reported that 7 parents out of 12 observed discoloration although double antibiotic paste (DAP) and non-bismuth-containing Port- Parameter (Mean ± SD) p value land cement were used. Visual assessment of discoloration by the two assessors at Group (N) Group (W) 12 months was similar to the results reported by parents. Difference (mm) 1.03 ± 0.97 1.04 ± 0.86 0.979 ns However, assessors reported discoloration at an earlier time this Percentage change (%) 8.52 ± 3.33 8.64 ± 4.30 0.973 ns was due to the fact reported by Vichi et al. [34] that skilled operators perceive color difference at earlier levels than untrained Clinical follow-up protocol was planned to be after 1 week, observers. 1 month, 3 months, 6 months, and 12 months in accordance with Although NeoMTA showed less discoloration potential com- previous literature assessing and evaluating discoloration quanti- pared to WMTA angelus, there was no statistically signiﬁcant tatively [10, 28, 29]. difference between both groups. Little information is currently The covid-19 pandemic lockdown caused unique challenges for available on NeoMTA, the results of the NeoMTA group were in the clinical trial community around the world [30]. The effect of line with the conclusion of the invitro study done by Camilleri, [35] lockdown was noticed in the present study in the 6 months’ that NeoMTA has better color stability than conventional WMTA records as all patients were not able to attend the clinic. Also, it led because of its new formulation that replaced the bismuth oxide to the drop out of 5 children having 8 treated teeth as their with tantalum oxide. The result of discoloration outcome of the parents were unwilling to come for completion of the follow-up WMTA in the present study was in agreement with Nagata et al. period even after the end of lockdown although they didn’t have [36] that reported only 3 teeth out of 11 (27.3%) showed their ﬁnal composite build-up. Since the dropout was within the discoloration in revascularization protocol using non-staining number calculated in the sample size, there was no need to intracanal medication and WMTA (Angelus) that was placed compensate any of the dropout patients. above collagen matrix. On the contrary, other clinical studies In the present study, boys to girls distribution were 18 boys reported a higher percentage of discoloration in revascularization (60%) and 12 girls (40%) respectively. This ﬁnding could be related procedures using non-staining intracanal medication and WMTA to the results observed by El-Kenany et al. [31] that indicated a as Kahler et al. [37] reported discoloration in 10 cases out of 16 gender difference in injury rates among 8–12 years old school and Aly et al. [2] reported discoloration in (53.84%) of cases. children in Egypt. This might be related to boys’ tendency of These contradictory results might be explained by slightly choosing more energetic, active, and vigorous outdoor games. different clinical procedures. First, it was found that in the present Regarding the clinical outcomes, both groups were (100%) study WMTA was not in direct contact with the blood clot, it was clinically successful as there were a complete absence of pain on placed on collagen matrix, while in the aforementioned clinical biting, pain on percussion, swelling, sinus/ﬁstula, and mobility in studies, WMTA was in direct contact with blood without collagen both groups during all follow-ups. This could be explained by the matrix. The use of synthetic resorbable matrix over the blood clot, standardized disinfection protocol and the good coronal seal used separating it from the barrier materials was suggested by Žižka in both groups. The clinical outcomes were consistence with the et al. [38] and Wei X et al. [26] as a way for minimizing ﬁndings of Aly et al. [2] and Rizk [23]. On the contrary, a study discoloration in REP, but no available clinical trials conﬁrmed this done by Linsuwanont et al. [32] reported a lower clinical success postulation. rate as (76%) of cases were successful, the author explained that The later postulation was supported by Lenherr et al. [10] and the root canal disinfection protocol was not effective. Žižka et al. [38] that WMTA and all calcium silicate-based cements Evaluation of discoloration was done in the present study by 3 containing bismuth oxide or other radiopaciﬁers showed exacer- methods. Concerning the discoloration as reported by the parents, bated discoloration after contact with blood due to absorption of only one parent (9.1%) in Group (N) and surprisingly only three blood disintegration products into the porosities of freshly unset BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 7 Digital periapical radiographic images of immature upper right lateral incisor representative for Group (N) showing continuing root lengthening. a Baseline immediate post-operative radiograph showing the immature root of upper right lateral incisor. b 12 months follow-up radiograph showing the increase in root length in upper right lateral incisor. Fig. 8 Digital periapical radiographic images of immature upper right central incisor representative for Group (W) showing continuing root lengthening. a Baseline immediate post-operative radiograph showing the immature root of upper right central incisor. b 12 months follow-up radiograph showing the increase in root length in upper right central incisor. materials, Thus, concluded that allowing the coronal plug initial and ﬁnal color of the tooth over time. The mean ΔE value materials to set away from blood is beneﬁcial in decreasing showed no statistically signiﬁcant difference between both discoloration. materials during the 12 months, this might be explained by that The second explanation for the conﬂicting results of WMTA ΔE quantiﬁes the color change but not the direction. It is only might be related to the position of WMTA in relation to CEJ. In the when the different components of color, L* a * b*, are analyzed present study, WMTA was placed accurately just below CEJ with individually that the nature of the color change can be identiﬁed. the aid of collagen matrix, While Kahler et al. [37] and Aly et al. [2] The direction of color change in the WMTA group towards reported that controlling the position of WMTA above the blood decreased luminosity, and reduction of redness and yellowness clot was technically difﬁcult and the authors justiﬁed that one of thus increasing the tendency towards green and blue direction the possible causes of discoloration was the presence of WMTA agreed with Ioannidis et al. [14] and Esmaeili et al. [39], however, above the CEJ. This was in line with Žižka et al. [38] the present study showed less values of change. This difference in recommendation that placing the coronal barrier just below CEJ values could be explained by different study settings, as those makes the discoloration of tooth structure be covered by bone or studies were performed in laboratory conditions, which do not gingiva. reﬂect the actual clinical conditions. As in the present study WMTA Concerning the quantitative assessment of color change. The was applied carefully in areas of aesthetic concern just below CEJ smaller the ΔE value, the lower the color difference between the to reduce the risk of material-induced tooth discoloration and the BDJ Open (2023) 9:17 H.A. Tawfeek et al. discoloration of tooth structure might be covered by bone or for further root development in the regeneration procedure is the gingiva. disinfected root canal, whenever a sufﬁciently disinfected Esmaeili et al. [39] clariﬁed that variable amounts of color environment was created this allows a biological response of change were reported with the same formulation of WMTA would appropriate cells to support the continued root development. be as a result of different thicknesses of the remaining tooth All teeth in both groups were free of internal and external root structure, colorimetric method of measurement, and material resorption. However, Mittmann et al. [43] reported (56.3%) of teeth application methods. Accordingly, direct comparisons and inter- developed root resorption, but this could be explained by pretation of the available data concerning ΔE and different different case selections as resorption is more likely to be due components of color, L* a * b* values were difﬁcult to be to great damage to periodontal ligament due to luxation injuries performed due to the different experimental methodologies. rather than by the revascularization treatment. The proposed limit for color difference adopted in this study All teeth in both groups showed a complete absence of any was set at 3.7 ΔE units (perceptibility threshold), as there was a radiographic signs of infection, accordingly, all the teeth in both lack of consensus in the literature about the perceptibility groups were having 100% radiographic success and 100% overall threshold set value ranging between 2.6 and 3.7, it was set at success rate, this was in agreement with Kahler et al. [37] and Rizk, the highest value in the present study since it was suggested that [23] reported 100% overall clinical and radiographic success rate, clinicians are more tolerant of color difference in a clinical scenario and was comparable to systematic review and meta-analysis done than under controlled in vitro conditions [15]. Therefore, although by Koç & Del Fabbro, [20] reported that overall success rate of the mean ΔE value was more in the WMTA group than the revascularization procedures in teeth with traumatic injuries was NeoMTA group both materials were below the perceptibility 94.8%. This shows that the primary outcome of revascularization threshold. (elimination of clinical symptoms and resolution of apical period- In the present study, the ΔE value of WMTA was in agreement ontitis) can be easily achieved as long as the infection is controlled with the invitro study conducted by Rouhani et al. [40] and Beatty [4]. & Svec, [41] that reported the ΔE value of WMTA was 3.54, and 2.6 There was no statistically signiﬁcant difference in the overall respectively. While in terms of visual perception, they were not success rate between the two groups but this could be explained consistence together since the perceptibility threshold value was by the fact reported by Khan et al. [8] that NeoMTA is a pure MTA different. with a new formulation having alternative radiopaciﬁers, so it is On the contrary Ioannidis et al. [14] reported a higher ΔE value exhibiting physical and chemical properties compared with for WMTA than the present study this might be explained by Žižka conventional WMTA. et al. [38] that if recommendations are meticulously followed the level of discoloration of teeth can be minimized below the human Study limitations eye threshold. On the other hand, a clinical study done by Nazzal et al. [33] 1. COVID-19 pandemic lockdown affected the attendance of reported that post-revascularization discoloration occurred with patients to follow-up. ΔE value = 7.9, although the intracanal medication was minocy- 2. Comparing and interpreting the results of the present study cline free and the coronal plug material was non-bismuth with other clinical studies was difﬁcult because clinical containing Portland cement that was placed directly above blood protocols among the previous studies were widely varied. clot. This supports the postulation that the cause of discoloration 3. The data from in-vitro or in-vivo studies on NeoMTA was is multifactorial and doesn’t depend solely on the radio paciﬁer of scarce. coronal plug material or the intra-canal medication. Regarding the radiographic outcomes, the mean initial pre- What this paper adds operative root length of teeth showed no statistically signiﬁcant difference between both groups, which indicates that the 2 1. Both NeoMTA and conventional WMTA were successful groups were comparable and there was no variability between the coronal plug materials in the revascularization of non-vital selected teeth in both groups. immature permanent teeth achieving a high level of clinical The change in root length results were generated in millimeter and radiographic success. units and as percentage change from preoperative values as well, 2. NeoMTA is a promising coronal plug material that can be this was to provide a more conservative analysis as each case is used for revascularization procedures in the esthetic zone as normalized to its pre-operative measurement. In addition, the it showed less discoloration potential compared with units of percentage change provide a clinically meaningful conventional WMTA, however, there was no statistically outcome when considering the impact of REPs [2]. signiﬁcant difference between both groups. Continued root lengthening observed in this study was in 3. Coronal discoloration in the regenerative endodontic consistence with the results of Nagy et al. 2014 [42] reported the procedure is a multifactorial process not only related to mean increase in root length was 0.8 ± (0.5) mm, 5% and also was the composition of materials used but other factors might comparable to Aly et al. [2] results as the mean increase in root minimize or exacerbate the discoloration potential. length was 0.7 (± 0.23) mm, 5.02% in immature teeth treated with 4. If clinical guidelines and recommendations were scrupu- the same protocol as the present study using (DAP) and WMTA. lously followed, the degree of teeth discoloration might be On the contrary Mittmann et al. [43] reported that the reduced below the human eye perceptibility threshold. percentage of increase in root length was 0.96% during 22 months follow-up. This contradictory data can be explained by different case selections as the aforementioned study done by Mittmann et al. [43] included luxation injuries and replanted avulsed teeth DATA AVAILABILITY that have a higher risk of (HERS) or apical papilla injury, which are Data are available upon reasonable request. described as the most important elements controlling continuing of root development. REFERENCES There was no statistically signiﬁcant difference in the increase in root length in mm and percentage between the two groups. This 1. Galler KM, Krastl G, Simon S, Van Gorp G, Meschi N, Vahedi B, et al. European Society of Endodontology position statement: Revitalization procedures. Int End might be explained by the postulation of Kharchi et al. [25] that J. 2016;49:717–23. regardless of the REP details, the single most important variable BDJ Open (2023) 9:17 H.A. Tawfeek et al. 2. Aly MM, Taha SEED, El Sayed MA, Youssef R, Omar HM. Clinical and radiographic 29. Dettwiler CA, Walter M, Zaugg LK, Lenherr P, Weiger R, Krastl G. 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The Discoloration effect of White Mineral Trioxide Aggregate (WMTA), Calcium AUTHOR CONTRIBUTIONS Enriched Mixture (CEM), and Portland Cement (PC) on Human Teeth. J Clin Exp Conception and design of the study: HAT, AAEl-B, MA, RY. Acquisition of data: HAT. Dent. 2017;9:1397–401. Analysis and interpretation of data: HAT, AMAAl-S. Drafting the manuscript: HAT. 19. Chu SJ, Trushkowsky RD, Paravina RD. Dental color matching instruments and Revising the manuscript critically for important intellectual content: AAEl-B, MA, RY, systems. Review of clinical and research aspects. J Dent. 2010;38:2–16. AMAAl-S. Approval of the version of the manuscript to be published: HAT, AAEl-B, 20. Koç S, Del Fabbro M. Does the etiology of pulp necrosis affect regenerative MA, RY, AMAAl-S. endodontic treatment outcomes? A systematic review and meta-analyses. J Evid Base Dent Pr. 2020;20:1–18. 21. Douglas RD, Steinhauer TJ, Wee AG. Intraoral determination of the tolerance of dentists for perceptibility and acceptability of shade mismatch. J Prosthet Dent. FUNDING 2007;97:200–8. Open access funding provided by The Science, Technology & Innovation Funding 22. Day PF, Duggal MS, High AS, Robertson A, Gregg TA, Ashley PF, et al. Dis- Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). coloration of teeth after avulsion and replantation: Results from a multicenter randomized controlled trial. J Endod. 2011;37:1052–7. 23. Rizk HM. Regenerative endodontic treatment of bilateral necrotic immature COMPETING INTERESTS permanent maxillary central incisors with platelet-rich plasma versus blood clot: The authors declare no conﬂict of interest. The Research Ethics Committee, Faculty of A split mouth double-blinded randomized controlled trial. Int J Clin Pediatr Dent. Dentistry, Cairo University approved the protocol of this study with (reference no.18/ 2019;12:332–9. 7/52). Detailed procedures, beneﬁts, and expected harms were discussed with the 24. Martin DE, De Almeida JFA, Henry MA, Khaing ZZ, Schmidt CE, Teixeira FB, et al. child’s legal guardian, then informed consent was obtained. Concentration-dependent effect of sodium hypochlorite on stem cells of apical papilla survival and differentiation. J Endod. 2014;40:51–5. 25. Kharchi AS, Tagiyeva-Milne N, Kanagasingam S. Regenerative endodontic procedures, disinfectants and outcomes: A systematic review. Prim Dent J. ADDITIONAL INFORMATION 2020;9:65–84. Correspondence and requests for materials should be addressed to Hala Ahmed 26. Wei X, Yang M, Yue L, Huang D, Zhou X, Wang X, et al. Expert consensus on Tawfeek. regenerative endodontic procedures. Int J Oral Sci. 2022;14:55. 27. Burki Z, Watkins S, Wilson R, Fenlon M. A randomised controlled trial to inves- Reprints and permission information is available at http://www.nature.com/reprints tigate the effects of dehydration on tooth colour. J Dent. 2013;41:250–7. 28. Yoldaş SE, Bani M, Atabek D, Bodur H. Comparison of the potential discoloration Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims effect of bioaggregate, biodentine, and white mineral trioxide aggregate on in published maps and institutional afﬁliations. bovine teeth: In vitro research. J Endod. 2016;42:1815–8. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. 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eISSN: 2056-807X
DOI: 10.1038/s41405-023-00143-x
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Abstract

www.nature.com/bdjopen ARTICLE OPEN Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial) 1✉ 2 3 2 Hala Ahmed Tawfeek , Adel Abdel-Azim El-Bardissy , Mohammed Abou El-Yazeed , Randa Youssef and Ahmed Mohamed Abd Alsamad © The Author(s) 2023 OBJECTIVE: To evaluate and compare clinically and radiographically the effect of using two different coronal plug materials (NeoMTA versus Conventional White mineral trioxide aggregate) in revascularization of non-vital immature permanent anterior teeth, with special reference to the assessment and evaluation of discoloration potential over a period of one year. METHODS: Revascularization procedure was performed in (30) immature permanent non-vital anterior teeth which were randomly allocated to two equal groups (n = 15). NeoMTA was used as coronal plug material in the Experimental Group (N), while conventional White mineral trioxide aggregate (WMTA) was used as a coronal plug material in the Control Group (W). All treated teeth were evaluated clinically at 1 week, 1, 3, and 12 months and radiographically at 12 months. RESULTS: The overall clinical and radiographic success rate of Groups (N) and (W) at the end of the 12-month follow-up period was 100%. The discoloration was detected in a single tooth (9.1%) in Group (N) and three teeth (27.3%) in Group (W) but the difference between groups was not statistically signiﬁcant. CONCLUSIONS: Both NeoMTA and conventional WMTA were successful coronal plug materials in the revascularization of non-vital immature permanent teeth achieving a high level of clinical and radiographic success. NeoMTA is a promising coronal plug material that can be used for revascularization procedures in the esthetic zone as it showed less discoloration potential compared with conventional WMTA, however, there was no statistically signiﬁcant difference between both materials. BDJ Open (2023) 9:17 ; https://doi.org/10.1038/s41405-023-00143-x INTRODUCTION Revascularization treatment is based on the postulation that is Pulp necrosis of immature permanent teeth is considered a critical creating an environment free of microorganisms with a proper condition because it leads to the arrest of root development and bacterial-tight seal in the presence of an appropriate three- incomplete dentin deposition leaving a weak fragile root that is dimensional scaffold, stem/progenitor cells inside the root canal; more liable to fracture, it will also lead to a poor crown/root ratio stimulates tissue repair in nonvital immature permanent teeth [1, 3, 6]. with a possible periodontal breakdown [1–3]. Mineral trioxide aggregate (MTA) has been widely used in Several techniques have been used for the management of non- revascularization procedures for coronal sealing in more than 85% vital immature permanent teeth including calcium hydroxide of studies because of its biocompatibility, good sealing properties, apexiﬁcation and apical plug technique. Although these techniques and marginal adaptation. However, its poor handling character- were successful in achieving apical closure and healing of the istics and potential coronal discoloration effects are the major periapical pathosis, they do not contribute to any quantitative or disadvantages of using white mineral trioxide aggregate (WMTA) qualitative increase in root dimensions since a hard tissue barrier [7, 8]. formation only occurs apically without further root development [2]. The NeoMTA (NuSmile, Huston, USA) is pure MTA that is Revascularization is a regenerative endodontic procedure (REP) marketed as a cost-effective MTA intended to be used for pediatric that stimulates the continuation of root development. It is pulp therapy as it has fast setting time, easy handling and most considered a valuable treatment as it strengthens the root walls important modiﬁcation is its non-staining formulation. Tantalum by stimulating the deposition of hard tissues and promoting the oxide (Ta O ) has been added to NeoMTA as a radiopacifying 2 5 development of normal apical morphology [4, 5]. agent instead of bismuth oxide (Bi O ) which has been linked 2 3 Pediatric Dentistry, Orthodontics and Pediatric Dentistry Department, Oral and Dental Research Institute, National Research Centre, Giza, Egypt and Phd student in Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Cairo University, Giza, Egypt. Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Cairo University, Giza, 3 4 Egypt. Pediatric Dentistry, Orthodontics and Pediatric Dentistry Department, Oral and Dental Research Institute, National Research Centre, Giza, Egypt. Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University, Giza, Egypt. email: at.mohamed@nrc.sci.eg Received: 12 January 2023 Revised: 7 March 2023 Accepted: 23 March 2023 1234567890();,: H.A. Tawfeek et al. mainly to the cause of discoloration in conventional mineral trioxide aggregate [8, 9]. Revascularization of immature permanent teeth has become an important part of endodontic treatment modalities. Despite its high success rate clinically and radiographically, many studies have reported that discoloration is a signiﬁcant esthetic concern following revascularization procedure as appearance and pleasing esthetics are patient-centered outcomes [7]. Most currently available clinical trials mainly focus on clinical and radiographic outcomes of materials in addition to reporting their discoloration potential only in binary ways. Available data concerning the quantitative assessment of discoloration of new materials are from in-vitro studies bear in mind the difference in a clinical scenario than under controlled in-vitro conditions. So, this study aimed to evaluate clinically and radiographically the effect of using two types of Fig. 1 Radiographic stent (acrylic bite block) and shadow of the coronal plug materials in the revascularization of non-vital immature embedded stainless-steel wire appearing. permanent anterior teeth with special reference to assessment and evaluation of discoloration potential over a period of one year. SUBJECTS AND METHODS The Research Ethics Committee, Faculty of Dentistry, Cairo University approved the protocol for this parallel, double-blinded, randomized controlled trial with a 1:1 allocation ratio with (reference no.18/7/52). The study has been registered on Clinicaltrials.gov with identiﬁcation number: NCT03545139, under the title Clinical & Radiographic Evaluation of NeoMTA Versus Conventional White MTA in Revascularization of Non- Vital Immature Permanent Teeth. The trial was conducted from September 2019 to January 2021. Sample size determination Sample size determination was done before the study using R statistical package version 3.3.1. The T-test power calculation was used to detect the proper sample size based on the results of Lenherr et al. [10]. A total sample size of 22 (teeth) was found to be adequate to detect a mean difference in color change between study groups of 3.5 points (SD = ± 2.44) with a power of 90% and a two-sided signiﬁcance level of 5%; with equal allocation to two arms (11 teeth in each group). To compensate for Fig. 2 Individualized extension cone paralleling index. 30% non-response rate or possible patient attrition, the sample was increased to a total size of 30 (teeth) that were divided into 2 groups. Endodontology for revitalization’s pre-operative diagnostic procedures [1]. – Conventional pre-operative periapical radiograph was taken. Study setting – Detailed procedures, beneﬁts, and expected harms were discussed – A total of 30 non-vital immature permanent anterior teeth in 25 with the child’s legal guardian, then informed consent was obtained. children were enrolled in this study from the outpatient clinic of the – Preparation for digital radiographic procedures and construction of Pediatric Dentistry Department, Faculty of Dentistry, Cairo University. radiographic stent was done to perform an individualized Extension – The procedures were carried out by the main investigator for all patients. Cone Paralleling (XCP) index for each patient according to Aly et al. [2]. A radio-opaque object of known dimension (5 mm stainless steel wire) was embedded in the acrylic stent before setting [11]as shown in Figs. 1, 2. Eligibility criteria Inclusion criteria. Randomization and allocation concealment – 8–15 years old children. The 30 permanent immature teeth were randomly assigned by simple – Free from any systemic diseases. randomization procedure into two equal groups, Experimental Group (N): – Upper traumatized permanent anterior teeth with non-vital pulp and TM 15 teeth treated with NeoMTA (NuSmile Neo MTA ) and Control Group immature root apex. (W): 15 teeth treated with Conventional WMTA (White Angelus MTA) using – Pulp space not needed for post and core. shufﬂed closed white opaque envelopes picked by a patient at the second appointment just before placement of the coronal plug step. Exclusion criteria. Blinding – Poor oral hygiene. – The participants and legal guardians were blinded. – Teeth with root resorption, luxation injuries, and root fracture. – Radiographic assessor, one of the clinical assessors for the color – Teeth with severe discoloration/ unacceptable color difference change to avoid detection bias, and the statistician were blinded to between affected tooth and contralateral tooth (ΔE ≥ 5). avoid reporting bias. Pre-operative protocol Intraoperative procedures – Personal, medical, dental, trauma history, and clinical examination Treatment of the selected teeth was performed according to AAE [12] were attained based on the checklist of the European Society of clinical considerations for a regenerative procedure, same procedures were BDJ Open (2023) 9:17 H.A. Tawfeek et al. BDJ Open (2023) 9:17 Table 1. Participant timeline for enrollment, treatment procedures and follow up. Study period Enrolment Treatment procedures Follow up Close out Time point (Resistant cases) T T 1st appointment 2nd app 4 w 4w T1 1w T2 1m 33m T46m x 12m (T ) Enrolment Eligibility screen X Verbal interview X Diagnostic chart X Clinical examination X Preoperative conventional periapical X X-ray Preoperative photograph X Preoperative color assessment of X affected tooth Informed consent X Allocation X Impression for Radiographic stent X Intervention Access cavity X Minimal mechanical debridement X Irrigation X Antimicrobial dressing X Removal of antimicrobial dressing x X Inducing bleeding X X Placement of collagen plug X X Placement of coronal plug material XX Access cavity sealing X X Composite buildup X Assessment Color assessment XX x x X X x (baseline) then follow ups Clinical assessment X X X X X X x Immediate post operative Digital XX X x Radiograph and follow ups H.A. Tawfeek et al. applied to all teeth in the study the only difference was the coronal plug were asked about pain, and change in color if present. Parents were material used. taught how to examine visually the vestibule. Moreover, parents were requested to send an intra-oral photo if possible. All the data that were collected during this period were just to check on patients but were First appointment for revascularization procedure. Each tooth was locally not used for statistical analysis. anesthetized using topical anesthesia gel benzocaine 20% followed by – Composite build-up (3 M, Filtek, Z350, United Kingdom) was done to all labial inﬁltration using Articaine HCL 4% with 1:100,000 epinephrine then fractured teeth after the end of 12 month follow-up period to eliminate isolated with a rubber dam. A conventional access cavity was done then the masking effect of restoration on evaluation of discoloration. the working length was determined radiographically. Passive pressure irrigation using 1.5% sodium hypochlorite (NaOCl) (20 mL/canal, 5 min) In the follow-up visit the treated teeth were evaluated for: with a side vent needle placed 1–2 mm from the apex, then sterile Clinical parameters: physiological saline (5 mL), followed by 17% Ethylenediaminetetraacetic acid (EDTA) (20 mL/canal, 5 min). Canal dryness was performed using suitable size paper points then placement of intracanal medication (double a. Pain on biting: reported by asking the patient about the presence of antibiotic paste) prepared from equal amounts of Ciproﬂoxacin 500 mg pain while biting (Yes/No). and Metronidazole 500 mg with a ratio of 1:1. The mix was delivered into b. Pain on percussion: detected by tapping the tooth with the back of the canal using a disposable plastic syringe having plastic tips adjusted to an autoclavable mirror. be 2 mm shorter than the working length. The excess paste was removed, c. Presence of swelling, sinus, or ﬁstula: checked by visual examination and the access cavity was sealed with dry cotton and 3–4 mm of light- and palpation of the labial vestibule and the palatal area related to cured resin-modiﬁed glass ionomer (RMGI) (Riva, SDI, Australia) then the every affected tooth. patient was dismissed for 4 weeks. d. Mobility: was examined using the back of 2 autoclavable mirrors. The unit of measuring these parameters was binary (present/absent). Second appointment: (4 weeks after the First appointment). After 4 weeks, Discoloration: the response to the initial treatment done at the ﬁrst appointment was assessed. a. Parental reporting of discoloration: by verbally asking parents whether they noticed visually the presence/absence of change in Criteria of clinical success or failure of the ﬁrst appointment tooth color. according to the AAE [12]: Complete resolution of signs and b. Visual assessment of discoloration by two assessors (the main symptoms which include pain, swelling, sinus, or ﬁstula was considered investigator and another clinical assessor) reported the presence/ success of the ﬁrst appointment. absence of tooth color change (Binary outcome) detected by visual examination. Tooth color assessment: 1. Tooth color baseline T was recorded for the affected tooth at the – Cohen’s kappa value was used to assess the agreement between the 2 beginning of the second appointment using VITA Easyshade V assessors. digital spectrophotometer, three measurements were recorded then the mean color was calculated. 2. Intraoral photographs were captured for documentation using ﬁxed c. Quantitative assessment of color change: settings of the camera with no ﬂash [13]. The spectrophotometer measured the color of teeth based on the Commission Internationale de I’Eclairage’s CIELAB color space system. The Operating procedures: Each tooth was locally anesthetized using L* a* b* system allows color speciﬁcation within a three-dimensional space topical gel and labial inﬁltration using 3% mepivacaine without where: vasoconstrictor. The temporary dressing was removed after isolation by rubber dam then irrigation with 17% (EDTA) (20 mL/canal, 5 min) followed a. The L* axis represents the degree of lightness within a tooth and by canal dryness. Bleeding was obtained by over-instrumenting and ranges from 0 (black) to 100 (white). rotating a pre-curved K-ﬁle at 2 mm past the canal to have the entire canal b. The a* plane represents the degree of green–red within a tooth, a* ﬁlled with blood. A tight cotton pellet slightly wetted with sterile saline was values ranges from red (+80a*) to green (−80a*). inserted and left for 10–15 min to allow the formation of a clot then c. The b* plane represents the degree of blue–yellow within the tooth cleaning of any blood remnants on the walls of the cavity was done using and b* values range from yellow (+80b*) to blue (−80b*). a bond brush. A resorbable collagen matrix Colla-plug™ (Zimmer Dental Inc. Aston Avenue Carlsbad, CA, USA) was placed over the clot followed by – Three measurements were recorded for each follow-up then the mean placement of the coronal plug material according to the tooth allocated in color was calculated. which group, either NeoMTA (NuSmile Neo MTA™.) or conventional WMTA – The change in tooth color was calculated by monitoring changes in ΔL, (White Angelus MTA. Angelus Indústria de Produtos Odontológicos. Waldir Δ a, Δ b by subtracting the baseline measurements from the follow-up Landgraf Street- Londrina- Brazil) forming about 3 mm thickness just measurements. underneath the cementoenamel junction (CEJ). Excess material on the – Delta E (ΔE) is the total color difference or the distance between two cavity wall was removed, then a conventional periapical radiograph was colors, (ΔE) was calculated according to the following equation: taken to double-check the proper position of the coronal plug in relation 2 2 2 ½ ΔE = ([L _L ] + [a _a ] + [b _b ] ) [13, 14]. to CEJ. Once the material became ﬁrm within 10–15 min, RMGI followed by x 0 x 0 x 0 – The proposed limit for color difference adopted in this study was set at composite ﬁlling (3 M, Filtek, Z350, United Kingdom) was placed. 3.7 ΔΕ units (perceptibility threshold) which means how much color Immediate postoperative (baseline) digital radiograph was taken at the change is considered perceptible, differences beyond this limit were end of the second appointment using a Digital x-ray machine (Minray, considered clinically perceptible [14, 15]. Soredex, Tuusula); using a standardized paralleling technique by the (XCP) alignment system with the radiographic stent and the large 3 × 4 cm Radiographic Parameters: phosphor storage plates (PSPs) imaging plate (Soredex DIGORA®, Finland). The DIGORA Optime scanner scanned imaging plates. a. Presence of external or internal root resorption. – All patients were planned to be recalled for clinical follow-up after b. Assessment of periapical area: presence or absence of radiographic 1 week, 1 month, 3 months, 6 months, and 12 months while signs of infection. radiographic follow-up was planned to be at 6 months and 12 months c. Root lengthening: as shown in Table 1, but due to the Covid-19 lockdown, a modiﬁed follow up was done as all patients were not able to attend the six Root length was measured on the Digora software and the increase in months recall visit. Consequently, the following measures were done root length and percentage of change in root length were calculated using to assure the patients and their parents. Through a phone call, parents equations according to Aly et al. [2]. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 3 Flow Chart of the study population through the study. RESULTS Table 2. Age and gender distribution among study between two During the follow-up period, four cases (26.7%) dropped out from groups. each group and were excluded from the data analysis. Twenty children with 22 teeth completed the 12 months study period. The Groups Mean age Gender % ﬂow of the patients throughout the study is presented in Fig. 3. Male Female Regarding the demographic data age and gender distribution Group (N) 9.07 ± 0.96 66.7% 33.3% among study subjects, were presented in Table 2 with no statistically signiﬁcant difference within both groups (p-value= Group (W) 9.43 ± 1.55 53.3% 46.7% 0.443 and 0.771 respectively). Regarding the evaluation of clinical outcomes, all teeth showed Increase in length = 12 m follow-up root length—immediate post- normal clinical ﬁndings, there was a complete absence of signs operative root length and symptoms such as pain on biting, pain on percussion, Percentage of change in length = 12 m follow-up root length—immediate swelling, sinus/ﬁstula, and mobility in both groups during all post-operative root length /immediate post-operative root length x 100. follow-ups so both groups were (100%) clinically successful with no statistically signiﬁcant difference between groups. Concerning evaluation of discoloration, none of the parents Statistical analysis The results of the present study were interpreted using per-protocol reported discoloration at the 1-week follow-up, at 1 month only analysis. one parent in Group (N) reported the presence of discoloration in Categorical data presented as frequencies and percentages were one tooth (9.1%) and two parents in Group (W) reported analyzed using the Chi-square test. Quantitative data were explored for discoloration in 2 teeth (18.2%), at 3 and 12 months follow up normality using Kolmogorov-Smirnov and Shapiro-Wilk tests and were only one parent in Group (N) reported discoloration at one tooth found to follow the normal distribution, so they were presented as mean (9.1%) and three parents in Group (W) reported discoloration in 3 and standard deviation (SD) and were analyzed using the independent teeth (27.3%) and the difference between groups was not t-test with the signiﬁcance level set at p ≤ 0.05 for all tests. Cohen’s kappa statistically signiﬁcant (p value = 0.269). value was used to assess the agreement between raters. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Table 3. Mean and Standard deviation (SD) values for ΔL, Δa, Δb in both groups. Parameter Interval (Mean ± SD) p-value Group (N) Group (W) ΔL 1 week- Baseline −0.50 ± 1.65 −1.29 ± 2.29 0.365 ns 1 month- Baseline −0.69 ± 1.78 −2.04 ± 2.24 0.134 ns 3 months- Baseline −1.05 ± 2.80 −2.20 ± 2.45 0.317 ns 12 months-Baseline −1.01 ± 3.17 −2.80 ± 2.77 0.173 ns Δa 1 week- Baseline 0.07 ± 0.34 −0.28 ± 0.48 0.070 ns 1 month- Baseline 0.12 ± 0.40 −0.27 ± 0.42 0.037* 3 months- Baseline 0.18 ± 0.28 −0.28 ± 0.44 0.011* 12 months- Baseline 0.20 ± 0.40 −0.23 ± 0.52 0.041* Δb 1 week- Baseline −0.20 ± 1.10 −0.69 ± 1.05 0.294 ns 1 month- Baseline −0.56 ± 1.55 −0.69 ± 1.07 0.813 ns 3 months- Baseline −0.45 ± 1.71 −0.71 ± 1.36 0.693 ns 12 months- Baseline −0.40 ± 2.20 −0.71 ± 1.67 0.713 ns *signiﬁcant (p ≤ 0.05) ns; non-signiﬁcant (p > 0.05). Fig. 4 Line chart showing mean values for ΔE in both groups. The discoloration was assessed visually by two clinicians and The mean Δb value of Group (W) was more than Group (N), in a there was an excellent agreement between both ratings of the direction indicating a reduction of yellow color thus an increasing clinical data (k = 1, p < 0.001). At 1 week no discoloration was change towards the blue direction with no signiﬁcant difference detected in Group (N), while one tooth (9.1%) showed discolora- between groups. Mean and standard deviation values for ΔL, Δa, tion in Group (W). At 1 month, discoloration was detected in one Δb are presented in Table 3. tooth (9.1%) in Group (N) and three teeth (27.3%) in Group (W). At The mean ΔE value at 12 months in the WMTA group was 3, 12 months follow-ups discoloration was detected in a single (ΔE = 3.64 ± 2.31) and NeoMTA group was (ΔE = 2.99 ± 2.56). No case (9.1%) in Group (N) and three cases (27.3%) in Group (W), and statistically signiﬁcant difference between both materials during the difference between groups was not statistically signiﬁcant (p the 12 months (p value = 0.535). Mean values for ΔE are presented value = 0.269). in Fig. 4. Clinical photographs showing the evaluation of The change in color between baseline and 12 months was discoloration in Group (N) and (W), Figs. 5 and 6. quantiﬁed for each tooth by measuring the CIE L*a*b* values and The mean and standard deviation values for initial root length calculation of ΔE. in mm were 11.694 (± 1.644) mm for Group (N) and At the end of 12 months, it was found that the mean ΔL value of 12.654(± 1.449) mm in Group (W). There was no signiﬁcant Group (W) was more than Group (N), in a direction indicating difference in mean initial root length in both groups (p- decreased luminosity with no signiﬁcant difference between value = 0.162). groups. Continued root lengthening was observed in this study, the The mean Δa value at the end of 12 months showed that Group mean increase in root length in mm and percentage between (N) remained in the red values direction, while Group (W) showed 12 months follow-up and pre-operative root length in Group (N) a reduction in redness thus an increasing change towards the was 1.03 (± 0.97) mm, 8.52(± 3.33)% and in Group (W) was 1.04 green direction. The alterations observed in the WMTA group (± 0.86) mm, 8.64(± 4.30)% with no signiﬁcant difference between were signiﬁcantly greater compared with the other group. both groups. Mean and Standard deviation (SD) values are shown BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 5 Clinical photographs of fractured upper left central incisor which was the single case that showed clinical discoloration in Group (N), change in color started to show at the 1 month follow up. a Baseline clinical photograph of upper left central incisor at second appointment, b Clinical photograph at 1 week follow up without discoloration, c Clinical photograph at 1 month follow-up showing shadow of cervical crown discoloration, d Clinical photograph at 3 months follow-up showing cervical crown discoloration, e Clinical photograph at 12 months follow-up showing cervical crown discoloration. f Clinical photograph showing composite buildup. in Table 4. Digital radiographs showing an increase in root length apical papilla (SCAPs) and Hertwig epithelial root sheath (HERS) in Group (N) and (W), Figs. 7, 8. might be damaged [20]. Regarding the radiographic evaluation, all teeth in both Groups The exclusion of cases with unacceptable discoloration (N) and (W) were free of internal and external root resorption also compared with the contralateral tooth was done in order not to there was a complete absence of any radiographic signs of affect the evaluation of discoloration that might occur. The infection, accordingly the overall clinical and radiographic success unacceptable discoloration limit for exclusion of cases (ΔE more rate was 100% for both Groups (N) and (W). than 5) was determined by following the intraoral perceptibility and acceptability tolerances for color mismatch reported in the literature, a difference of ΔE starting from 5.5 to 6.8 was required DISCUSSION for dentists to ﬁnd the color mismatch sufﬁciently unacceptable to Revascularization of immature permanent teeth has become an suggest further treatment to improve it [21, 22]. important part of endodontic treatment modalities. Despite its The radiographic standardization was done by the construction high success rate clinically and radiographically, the concerns of a radiographic stent for bite registration to facilitate consistent about post-revascularization tooth discoloration were increasing positioning of the ﬁlm. Moreover, (XCP) alignment system was [7]. This outcome is unfavorable and signiﬁcantly impacts the used for a paralleling technique to allow comparisons of the quality of life in children negatively, therefore materials with digital radiographs [2, 23]. A radio-opaque marker of known the lowest possible staining potential should be considered in the dimension was embedded in the acrylic resin stent to help in the esthetic zone. determination and compensation of the magniﬁcation factor of The cause of post-revascularization discoloration is still deba- the radiographic images thus minimizing errors in the measure- table, but most ﬁngers point to the presence of bismuth oxide in ment of root length [11]. the conventional WMTA and its reaction with dental tissues, blood Treatment procedures of the selected teeth were performed products, and irrigants used in revascularization procedures according to AAE [12] clinical considerations for a regenerative [16,17]. Although WMTA was developed to overcome tooth procedure. Lower concentrations of NaOCl (1.5 % concentration) discoloration encountered with the use of the Grey mineral were advised and recommended by AAE [12] to keep the balance trioxide aggregate (GMTA), several in vitro studies had reported between sufﬁcient disinfection and preservation of SCAPs. Since it evidence of tooth discoloration [14, 18]. has been proven that using higher concentrations of NaOCl has a Accordingly, NeoMTA was suggested as coronal plug material in profound negative effect on the survival and differentiation of the intervention group, since it is a pure WMTA that is marketed SCAPs or expression of proteins of the dentin matrix that are by having a new non-staining formulation, due to replacing the involved in promoting tissue regeneration [24–26]. radiopaciﬁer (Bi O ) with (Ta O ), moreover, it has been reported It was recommended by the AAE [12] to set the second 2 3 2 5 that it has better handling characteristics and forms putty appointment within 1–4 weeks from the ﬁrst appointment consistency upon mixing [8]. Therefore, it was recommended to according to the assessment of the response to initial treatment, investigate the material performance in various clinical Since it was a must to standardize the time of the second applications. appointment for all patients to limit any variables the maximum The inclusion and exclusion criteria of the present study have time interval given by the AAE was set for all patients to be able to been determined according to the AAE [12] clinical considerations take a decision either to proceed for a second visit or consider for regenerative procedures. Teeth showing severe coronal additional treatment time with antimicrobial. fracture were excluded from the study because the pulp space The baseline color assessment was done at the beginning of the won’t be available for post retention and the VITA Easyshade second appointment before the teeth are exposed to dehydration probe’s diameter is 5 mm so, at least 5 mm of intact cervical as recommended by Burki et al. [27] since most dental procedures enamel was needed to evaluate color changes [19]. Teeth with lead to teeth dehydration which alters tooth shade and shows luxation injuries were excluded since the stem cells from the perceivable color change causing errors in color assessment. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 6 Clinical photographs of 9 years old child presented with traumatized upper left central incisor enrolled in Group (W) showing clinical change in color that started to show at the 1 month follow up. a Baseline clinical photograph at second appointment, b Clinical photograph at 1 week follow up without discoloration, c Clinical photograph at 1 month follow-up showing shadow of cervical crown discoloration, d Clinical photograph at 3 months follow-up showing cervical crown discoloration, e Clinical photograph at 12 months follow- up showing cervical crown discoloration. f Clinical photograph showing composite buildup. parents (27.3%) in Group (W) reported discoloration at the end of Table 4. Mean and Standard deviation (SD) values for change in root 12 months. This result was not in line with Nazzal et al. [33] who length in (mm) and (%) in both groups. reported that 7 parents out of 12 observed discoloration although double antibiotic paste (DAP) and non-bismuth-containing Port- Parameter (Mean ± SD) p value land cement were used. Visual assessment of discoloration by the two assessors at Group (N) Group (W) 12 months was similar to the results reported by parents. Difference (mm) 1.03 ± 0.97 1.04 ± 0.86 0.979 ns However, assessors reported discoloration at an earlier time this Percentage change (%) 8.52 ± 3.33 8.64 ± 4.30 0.973 ns was due to the fact reported by Vichi et al. [34] that skilled operators perceive color difference at earlier levels than untrained Clinical follow-up protocol was planned to be after 1 week, observers. 1 month, 3 months, 6 months, and 12 months in accordance with Although NeoMTA showed less discoloration potential com- previous literature assessing and evaluating discoloration quanti- pared to WMTA angelus, there was no statistically signiﬁcant tatively [10, 28, 29]. difference between both groups. Little information is currently The covid-19 pandemic lockdown caused unique challenges for available on NeoMTA, the results of the NeoMTA group were in the clinical trial community around the world [30]. The effect of line with the conclusion of the invitro study done by Camilleri, [35] lockdown was noticed in the present study in the 6 months’ that NeoMTA has better color stability than conventional WMTA records as all patients were not able to attend the clinic. Also, it led because of its new formulation that replaced the bismuth oxide to the drop out of 5 children having 8 treated teeth as their with tantalum oxide. The result of discoloration outcome of the parents were unwilling to come for completion of the follow-up WMTA in the present study was in agreement with Nagata et al. period even after the end of lockdown although they didn’t have [36] that reported only 3 teeth out of 11 (27.3%) showed their ﬁnal composite build-up. Since the dropout was within the discoloration in revascularization protocol using non-staining number calculated in the sample size, there was no need to intracanal medication and WMTA (Angelus) that was placed compensate any of the dropout patients. above collagen matrix. On the contrary, other clinical studies In the present study, boys to girls distribution were 18 boys reported a higher percentage of discoloration in revascularization (60%) and 12 girls (40%) respectively. This ﬁnding could be related procedures using non-staining intracanal medication and WMTA to the results observed by El-Kenany et al. [31] that indicated a as Kahler et al. [37] reported discoloration in 10 cases out of 16 gender difference in injury rates among 8–12 years old school and Aly et al. [2] reported discoloration in (53.84%) of cases. children in Egypt. This might be related to boys’ tendency of These contradictory results might be explained by slightly choosing more energetic, active, and vigorous outdoor games. different clinical procedures. First, it was found that in the present Regarding the clinical outcomes, both groups were (100%) study WMTA was not in direct contact with the blood clot, it was clinically successful as there were a complete absence of pain on placed on collagen matrix, while in the aforementioned clinical biting, pain on percussion, swelling, sinus/ﬁstula, and mobility in studies, WMTA was in direct contact with blood without collagen both groups during all follow-ups. This could be explained by the matrix. The use of synthetic resorbable matrix over the blood clot, standardized disinfection protocol and the good coronal seal used separating it from the barrier materials was suggested by Žižka in both groups. The clinical outcomes were consistence with the et al. [38] and Wei X et al. [26] as a way for minimizing ﬁndings of Aly et al. [2] and Rizk [23]. On the contrary, a study discoloration in REP, but no available clinical trials conﬁrmed this done by Linsuwanont et al. [32] reported a lower clinical success postulation. rate as (76%) of cases were successful, the author explained that The later postulation was supported by Lenherr et al. [10] and the root canal disinfection protocol was not effective. Žižka et al. [38] that WMTA and all calcium silicate-based cements Evaluation of discoloration was done in the present study by 3 containing bismuth oxide or other radiopaciﬁers showed exacer- methods. Concerning the discoloration as reported by the parents, bated discoloration after contact with blood due to absorption of only one parent (9.1%) in Group (N) and surprisingly only three blood disintegration products into the porosities of freshly unset BDJ Open (2023) 9:17 H.A. Tawfeek et al. Fig. 7 Digital periapical radiographic images of immature upper right lateral incisor representative for Group (N) showing continuing root lengthening. a Baseline immediate post-operative radiograph showing the immature root of upper right lateral incisor. b 12 months follow-up radiograph showing the increase in root length in upper right lateral incisor. Fig. 8 Digital periapical radiographic images of immature upper right central incisor representative for Group (W) showing continuing root lengthening. a Baseline immediate post-operative radiograph showing the immature root of upper right central incisor. b 12 months follow-up radiograph showing the increase in root length in upper right central incisor. materials, Thus, concluded that allowing the coronal plug initial and ﬁnal color of the tooth over time. The mean ΔE value materials to set away from blood is beneﬁcial in decreasing showed no statistically signiﬁcant difference between both discoloration. materials during the 12 months, this might be explained by that The second explanation for the conﬂicting results of WMTA ΔE quantiﬁes the color change but not the direction. It is only might be related to the position of WMTA in relation to CEJ. In the when the different components of color, L* a * b*, are analyzed present study, WMTA was placed accurately just below CEJ with individually that the nature of the color change can be identiﬁed. the aid of collagen matrix, While Kahler et al. [37] and Aly et al. [2] The direction of color change in the WMTA group towards reported that controlling the position of WMTA above the blood decreased luminosity, and reduction of redness and yellowness clot was technically difﬁcult and the authors justiﬁed that one of thus increasing the tendency towards green and blue direction the possible causes of discoloration was the presence of WMTA agreed with Ioannidis et al. [14] and Esmaeili et al. [39], however, above the CEJ. This was in line with Žižka et al. [38] the present study showed less values of change. This difference in recommendation that placing the coronal barrier just below CEJ values could be explained by different study settings, as those makes the discoloration of tooth structure be covered by bone or studies were performed in laboratory conditions, which do not gingiva. reﬂect the actual clinical conditions. As in the present study WMTA Concerning the quantitative assessment of color change. The was applied carefully in areas of aesthetic concern just below CEJ smaller the ΔE value, the lower the color difference between the to reduce the risk of material-induced tooth discoloration and the BDJ Open (2023) 9:17 H.A. Tawfeek et al. discoloration of tooth structure might be covered by bone or for further root development in the regeneration procedure is the gingiva. disinfected root canal, whenever a sufﬁciently disinfected Esmaeili et al. [39] clariﬁed that variable amounts of color environment was created this allows a biological response of change were reported with the same formulation of WMTA would appropriate cells to support the continued root development. be as a result of different thicknesses of the remaining tooth All teeth in both groups were free of internal and external root structure, colorimetric method of measurement, and material resorption. However, Mittmann et al. [43] reported (56.3%) of teeth application methods. Accordingly, direct comparisons and inter- developed root resorption, but this could be explained by pretation of the available data concerning ΔE and different different case selections as resorption is more likely to be due components of color, L* a * b* values were difﬁcult to be to great damage to periodontal ligament due to luxation injuries performed due to the different experimental methodologies. rather than by the revascularization treatment. The proposed limit for color difference adopted in this study All teeth in both groups showed a complete absence of any was set at 3.7 ΔE units (perceptibility threshold), as there was a radiographic signs of infection, accordingly, all the teeth in both lack of consensus in the literature about the perceptibility groups were having 100% radiographic success and 100% overall threshold set value ranging between 2.6 and 3.7, it was set at success rate, this was in agreement with Kahler et al. [37] and Rizk, the highest value in the present study since it was suggested that [23] reported 100% overall clinical and radiographic success rate, clinicians are more tolerant of color difference in a clinical scenario and was comparable to systematic review and meta-analysis done than under controlled in vitro conditions [15]. Therefore, although by Koç & Del Fabbro, [20] reported that overall success rate of the mean ΔE value was more in the WMTA group than the revascularization procedures in teeth with traumatic injuries was NeoMTA group both materials were below the perceptibility 94.8%. This shows that the primary outcome of revascularization threshold. (elimination of clinical symptoms and resolution of apical period- In the present study, the ΔE value of WMTA was in agreement ontitis) can be easily achieved as long as the infection is controlled with the invitro study conducted by Rouhani et al. [40] and Beatty [4]. & Svec, [41] that reported the ΔE value of WMTA was 3.54, and 2.6 There was no statistically signiﬁcant difference in the overall respectively. While in terms of visual perception, they were not success rate between the two groups but this could be explained consistence together since the perceptibility threshold value was by the fact reported by Khan et al. [8] that NeoMTA is a pure MTA different. with a new formulation having alternative radiopaciﬁers, so it is On the contrary Ioannidis et al. [14] reported a higher ΔE value exhibiting physical and chemical properties compared with for WMTA than the present study this might be explained by Žižka conventional WMTA. et al. [38] that if recommendations are meticulously followed the level of discoloration of teeth can be minimized below the human Study limitations eye threshold. On the other hand, a clinical study done by Nazzal et al. [33] 1. COVID-19 pandemic lockdown affected the attendance of reported that post-revascularization discoloration occurred with patients to follow-up. ΔE value = 7.9, although the intracanal medication was minocy- 2. Comparing and interpreting the results of the present study cline free and the coronal plug material was non-bismuth with other clinical studies was difﬁcult because clinical containing Portland cement that was placed directly above blood protocols among the previous studies were widely varied. clot. This supports the postulation that the cause of discoloration 3. The data from in-vitro or in-vivo studies on NeoMTA was is multifactorial and doesn’t depend solely on the radio paciﬁer of scarce. coronal plug material or the intra-canal medication. Regarding the radiographic outcomes, the mean initial pre- What this paper adds operative root length of teeth showed no statistically signiﬁcant difference between both groups, which indicates that the 2 1. Both NeoMTA and conventional WMTA were successful groups were comparable and there was no variability between the coronal plug materials in the revascularization of non-vital selected teeth in both groups. immature permanent teeth achieving a high level of clinical The change in root length results were generated in millimeter and radiographic success. units and as percentage change from preoperative values as well, 2. NeoMTA is a promising coronal plug material that can be this was to provide a more conservative analysis as each case is used for revascularization procedures in the esthetic zone as normalized to its pre-operative measurement. In addition, the it showed less discoloration potential compared with units of percentage change provide a clinically meaningful conventional WMTA, however, there was no statistically outcome when considering the impact of REPs [2]. signiﬁcant difference between both groups. Continued root lengthening observed in this study was in 3. Coronal discoloration in the regenerative endodontic consistence with the results of Nagy et al. 2014 [42] reported the procedure is a multifactorial process not only related to mean increase in root length was 0.8 ± (0.5) mm, 5% and also was the composition of materials used but other factors might comparable to Aly et al. [2] results as the mean increase in root minimize or exacerbate the discoloration potential. length was 0.7 (± 0.23) mm, 5.02% in immature teeth treated with 4. If clinical guidelines and recommendations were scrupu- the same protocol as the present study using (DAP) and WMTA. lously followed, the degree of teeth discoloration might be On the contrary Mittmann et al. [43] reported that the reduced below the human eye perceptibility threshold. percentage of increase in root length was 0.96% during 22 months follow-up. This contradictory data can be explained by different case selections as the aforementioned study done by Mittmann et al. [43] included luxation injuries and replanted avulsed teeth DATA AVAILABILITY that have a higher risk of (HERS) or apical papilla injury, which are Data are available upon reasonable request. described as the most important elements controlling continuing of root development. REFERENCES There was no statistically signiﬁcant difference in the increase in root length in mm and percentage between the two groups. This 1. Galler KM, Krastl G, Simon S, Van Gorp G, Meschi N, Vahedi B, et al. European Society of Endodontology position statement: Revitalization procedures. Int End might be explained by the postulation of Kharchi et al. [25] that J. 2016;49:717–23. regardless of the REP details, the single most important variable BDJ Open (2023) 9:17 H.A. Tawfeek et al. 2. Aly MM, Taha SEED, El Sayed MA, Youssef R, Omar HM. Clinical and radiographic 29. Dettwiler CA, Walter M, Zaugg LK, Lenherr P, Weiger R, Krastl G. In vitro assess- evaluation of Biodentine and Mineral Trioxide Aggregate in revascularization of ment of the tooth staining potential of endodontic materials in a bovine tooth non-vital immature permanent anterior teeth (randomized clinical study). Int J model. Dent. Traumatol. 2016;32:480–7. Paediatr Dent. 2019;29:464–73. 30. Mitchell EJ, Ahmed K, Breeman S, Cotton S, Constable L, Ferry G, et al. It is 3. Caleza-Jiménez C, Ribas-Pérez D, Biedma-Perea M, Solano-Mendoza B, Mendoza- unprecedented: Trial management during the COVID-19 pandemic and beyond. Mendoza A. Radiographic differences observed following apexiﬁcation vs Trials 2020;21:1–7. revascularization in necrotic immature molars and incisors: a follow-up study of 31. El-Kenany MH, Awad SM, Hegazy SA. Prevalence and risk factors of traumatic 18 teeth. Eur Arch Paediatr Dent. 2022;23:381–9. dental injuries to permanent anterior teeth among 8–12 years old school children 4. Kim SG, Malek M, Sigurdsson A, Lin LM, Kahler B. Regenerative endodontics: A in Egypt. Pediatr Dent. J. 2016;26:67–73. comprehensive review. Int End J. 2018;51:1367–88. 32. Linsuwanont P, Sinpitaksakul P, Lertsakchai T. Evaluation of root maturation after 5. Zhou C, Yuan Z, Xu H, Wu L, Xie C, Liu J. Regenerative endodontic procedures in revitalization in immature permanent teeth with nonvital pulps by cone beam immature permanent teeth with dental trauma: Current approaches and chal- computed tomography and conventional radiographs. Int Endod J. 2017;50:836–46. lenges. Front Dent Med. 2022;2:1–9. 33. Nazzal H, Kenny K, Altimimi A, Kang J, Duggal MS. A prospective clinical study of 6. Sonkar T, Pathak N, Shetty S, Rathi A, Mohammed A, Viragi P. Mineral trioxide regenerative endodontic treatment of traumatized immature teeth with necrotic aggregate endodontic revascularization of nonvital anterior tooth. J Int Clin Dent pulps using bi-antibiotic paste. Int End J. 2018;51:204–15. Res Organ. 2022;14:48. 34. Vichi A, Louca C, Corciolani G, Ferrari M. Color related to ceramic and zirconia 7. Kahler B, Rossi-Fedele G. A review of tooth discoloration after regenerative restorations: A review. Dent Mater. 2011;27:97–108. endodontic therapy. J Endod. 2016;42:563–9. 35. Camilleri J. Staining potential of neo MTA Plus, MTA Plus, and biodentine used for 8. Khan J, El Housseiny A, Alamoudi N. Mineral Trioxide Aggregate Use in Pediatric pulpotomy procedures. J Endod. 2015;41:1139–45. Dentistry: A Literature Review. J Oral Hyg Heal. 2016;04:209. 36. Nagata JY, Figueiredo De Almeida Gomes BP, Rocha Lima TF, Murakami LS, De 9. Lozano-Guillén A, López-García S, Rodríguez-Lozano FJ, Sanz JL, Lozano A, Llena Faria DE, Campos GR, et al. Traumatized immature teeth treated with 2 protocols C, et al. Comparative cytocompatibility of the new calcium silicate-based cement of pulp revascularization. J Endod. 2014;40:606–12. NeoPutty versus NeoMTA Plus and MTA on human dental pulp cells: an in vitro 37. Kahler B, Mistry S, Moule A, Ringsmuth AK, Case P, Thomson A, et al. Revascu- study. Clin Oral Investig. 2022;26:7219–28. larization outcomes: A prospective analysis of 16 consecutive cases. J Endod. 10. Lenherr P, Allgayer N, Weiger R, Filippi A, Attin T, Krastl G. Tooth discoloration 2014;40:333–8. induced by endodontic materials: a laboratory study. Int End. J. 2012;45:942–9. 38. Žižka R, Šedý J, Gregor L, Voborná I. Discoloration after regenerative endodontic 11. Rino Neto J, de Paiva JB, Queiroz GV, Attizzani MF, Miasiro Junior H. Evaluation of procedures: A critical review. Iran Endod J. 2018;13:278–84. radiographic magniﬁcation in lateral cephalograms obtained with different X-ray 39. Esmaeili B, Alaghehmand H, Kordafshari T, Daryakenari G, Ehsani M, Bijani A. devices: Experimental study in human dry skull. Dent. Press J Orthod. Coronal discoloration induced by calcium-enriched mixture, mineral trioxide 2013;18:1–7. aggregate and calcium hydroxide: a spectrophotometric analysis. Iran Endod J. 12. AAE. AAE Clinical considerations for a regenerative procedure revised 4-1-18. Aae. 2016;11:23–8. 2018;1–6. 40. Rouhani A, Akbari M, Farhadi-Faz A. Comparison of tooth discoloration induced 13. Gurgan S, Cakir FY, Yazici E. Different light-activated in-ofﬁce bleaching systems: by calcium-enriched mixture and mineral trioxide aggregate. Iran Endod J. A clinical evaluation. Lasers Med Sci. 2010;25:817–22. 2016;11:175–8. 14. Ioannidis K, Mistakidis I, Beltes P, Karagiannis V. Spectrophotometric analysis of 41. Beatty H, Svec T. Quantifying coronal tooth discoloration caused by biodentine coronal discolouration induced by grey and white. MTA Int End J. 2013;46:137–44. and endosequence root repair material. J Endod. 2015;41:2036–9. 15. Khashayar G, Bain PA, Salari S, Dozic A, Kleverlaan CJ, Feilzer AJ. Perceptibility and 42. Nagy MM, Tawﬁk HE, Hashem AAR, Abu-Seida AM. Regenerative potential of acceptability thresholds for colour differences in dentistry. J Dent. immature permanent teeth with necrotic pulps after different regenerative 2014;42:637–44. protocols. J Endod. 2014;40:192–8. 16. Camilleri J. Color stability of white mineral trioxide aggregate in contact with 43. Mittmann CW, Kostka E, Ballout H, Preus M, Preissner R, Karaman M, et al. Out- hypochlorite solution. J Endod. 2014;40:436–40. come of revascularization therapy in traumatized immature incisors. BMC Oral 17. Zbańska J, Herman K, Kuropka P, Dobrzyński M. Regenerative endodontics as the Health. 2020;20:1–10. future treatment of immature permanent teeth. Appl Sci. 2021;11:6211. 18. Salem-Milani A, Ghasemi S, Rahimi S, Ardalan-Abdollahi A, Asghari-Jafarabadi M. The Discoloration effect of White Mineral Trioxide Aggregate (WMTA), Calcium AUTHOR CONTRIBUTIONS Enriched Mixture (CEM), and Portland Cement (PC) on Human Teeth. J Clin Exp Conception and design of the study: HAT, AAEl-B, MA, RY. Acquisition of data: HAT. Dent. 2017;9:1397–401. Analysis and interpretation of data: HAT, AMAAl-S. Drafting the manuscript: HAT. 19. Chu SJ, Trushkowsky RD, Paravina RD. Dental color matching instruments and Revising the manuscript critically for important intellectual content: AAEl-B, MA, RY, systems. Review of clinical and research aspects. J Dent. 2010;38:2–16. AMAAl-S. Approval of the version of the manuscript to be published: HAT, AAEl-B, 20. Koç S, Del Fabbro M. Does the etiology of pulp necrosis affect regenerative MA, RY, AMAAl-S. endodontic treatment outcomes? A systematic review and meta-analyses. J Evid Base Dent Pr. 2020;20:1–18. 21. Douglas RD, Steinhauer TJ, Wee AG. Intraoral determination of the tolerance of dentists for perceptibility and acceptability of shade mismatch. J Prosthet Dent. FUNDING 2007;97:200–8. Open access funding provided by The Science, Technology & Innovation Funding 22. Day PF, Duggal MS, High AS, Robertson A, Gregg TA, Ashley PF, et al. Dis- Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB). coloration of teeth after avulsion and replantation: Results from a multicenter randomized controlled trial. J Endod. 2011;37:1052–7. 23. Rizk HM. Regenerative endodontic treatment of bilateral necrotic immature COMPETING INTERESTS permanent maxillary central incisors with platelet-rich plasma versus blood clot: The authors declare no conﬂict of interest. The Research Ethics Committee, Faculty of A split mouth double-blinded randomized controlled trial. Int J Clin Pediatr Dent. Dentistry, Cairo University approved the protocol of this study with (reference no.18/ 2019;12:332–9. 7/52). Detailed procedures, beneﬁts, and expected harms were discussed with the 24. Martin DE, De Almeida JFA, Henry MA, Khaing ZZ, Schmidt CE, Teixeira FB, et al. child’s legal guardian, then informed consent was obtained. Concentration-dependent effect of sodium hypochlorite on stem cells of apical papilla survival and differentiation. J Endod. 2014;40:51–5. 25. Kharchi AS, Tagiyeva-Milne N, Kanagasingam S. Regenerative endodontic procedures, disinfectants and outcomes: A systematic review. Prim Dent J. ADDITIONAL INFORMATION 2020;9:65–84. Correspondence and requests for materials should be addressed to Hala Ahmed 26. Wei X, Yang M, Yue L, Huang D, Zhou X, Wang X, et al. Expert consensus on Tawfeek. regenerative endodontic procedures. Int J Oral Sci. 2022;14:55. 27. Burki Z, Watkins S, Wilson R, Fenlon M. A randomised controlled trial to inves- Reprints and permission information is available at http://www.nature.com/reprints tigate the effects of dehydration on tooth colour. J Dent. 2013;41:250–7. 28. Yoldaş SE, Bani M, Atabek D, Bodur H. Comparison of the potential discoloration Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims effect of bioaggregate, biodentine, and white mineral trioxide aggregate on in published maps and institutional afﬁliations. bovine teeth: In vitro research. J Endod. 2016;42:1815–8. BDJ Open (2023) 9:17 H.A. Tawfeek et al. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http:// creativecommons.org/licenses/by/4.0/. BDJ Open (2023) 9:17

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Published: Apr 28, 2023

References

European Society of Endodontology position statement: Revitalization procedures

Galler, KM; Krastl, G; Simon, S; Van Gorp, G; Meschi, N; Vahedi, B
Clinical and radiographic evaluation of Biodentine and Mineral Trioxide Aggregate in revascularization of non-vital immature permanent anterior teeth (randomized clinical study)

Aly, MM; Taha, SEED; El Sayed, MA; Youssef, R; Omar, HM
Radiographic differences observed following apexification vs revascularization in necrotic immature molars and incisors: a follow-up study of 18 teeth

Caleza-Jiménez, C; Ribas-Pérez, D; Biedma-Perea, M; Solano-Mendoza, B; Mendoza-Mendoza, A
Regenerative endodontics: A comprehensive review

Kim, SG; Malek, M; Sigurdsson, A; Lin, LM; Kahler, B
Regenerative endodontic procedures in immature permanent teeth with dental trauma: Current approaches and challenges

Zhou, C; Yuan, Z; Xu, H; Wu, L; Xie, C; Liu, J
Mineral trioxide aggregate endodontic revascularization of nonvital anterior tooth

Sonkar, T; Pathak, N; Shetty, S; Rathi, A; Mohammed, A; Viragi, P
A review of tooth discoloration after regenerative endodontic therapy

Kahler, B; Rossi-Fedele, G
Mineral Trioxide Aggregate Use in Pediatric Dentistry: A Literature Review

Khan, J; El Housseiny, A; Alamoudi, N
Comparative cytocompatibility of the new calcium silicate-based cement NeoPutty versus NeoMTA Plus and MTA on human dental pulp cells: an in vitro study

Lozano-Guillén, A; López-García, S; Rodríguez-Lozano, FJ; Sanz, JL; Lozano, A; Llena, C
Tooth discoloration induced by endodontic materials: a laboratory study

Lenherr, P; Allgayer, N; Weiger, R; Filippi, A; Attin, T; Krastl, G
Evaluation of radiographic magnification in lateral cephalograms obtained with different X-ray devices: Experimental study in human dry skull

Rino Neto, J; de Paiva, JB; Queiroz, GV; Attizzani, MF; Miasiro Junior, H
Different light-activated in-office bleaching systems: A clinical evaluation

Gurgan, S; Cakir, FY; Yazici, E
Spectrophotometric analysis of coronal discolouration induced by grey and white

Ioannidis, K; Mistakidis, I; Beltes, P; Karagiannis, V
Perceptibility and acceptability thresholds for colour differences in dentistry

Khashayar, G; Bain, PA; Salari, S; Dozic, A; Kleverlaan, CJ; Feilzer, AJ
Color stability of white mineral trioxide aggregate in contact with hypochlorite solution

Camilleri, J
Regenerative endodontics as the future treatment of immature permanent teeth

Zbańska, J; Herman, K; Kuropka, P; Dobrzyński, M
The Discoloration effect of White Mineral Trioxide Aggregate (WMTA), Calcium Enriched Mixture (CEM), and Portland Cement (PC) on Human Teeth

Salem-Milani, A; Ghasemi, S; Rahimi, S; Ardalan-Abdollahi, A; Asghari-Jafarabadi, M
Dental color matching instruments and systems. Review of clinical and research aspects

Chu, SJ; Trushkowsky, RD; Paravina, RD
Does the etiology of pulp necrosis affect regenerative endodontic treatment outcomes? A systematic review and meta-analyses

Koç, S; Del Fabbro, M
Intraoral determination of the tolerance of dentists for perceptibility and acceptability of shade mismatch

Douglas, RD; Steinhauer, TJ; Wee, AG
Discoloration of teeth after avulsion and replantation: Results from a multicenter randomized controlled trial

Day, PF; Duggal, MS; High, AS; Robertson, A; Gregg, TA; Ashley, PF
Regenerative endodontic treatment of bilateral necrotic immature permanent maxillary central incisors with platelet-rich plasma versus blood clot: A split mouth double-blinded randomized controlled trial

Rizk, HM
Concentration-dependent effect of sodium hypochlorite on stem cells of apical papilla survival and differentiation

Martin, DE; De Almeida, JFA; Henry, MA; Khaing, ZZ; Schmidt, CE; Teixeira, FB
Regenerative endodontic procedures, disinfectants and outcomes: A systematic review

Kharchi, AS; Tagiyeva-Milne, N; Kanagasingam, S
Expert consensus on regenerative endodontic procedures

Wei, X; Yang, M; Yue, L; Huang, D; Zhou, X; Wang, X
A randomised controlled trial to investigate the effects of dehydration on tooth colour

Burki, Z; Watkins, S; Wilson, R; Fenlon, M
Comparison of the potential discoloration effect of bioaggregate, biodentine, and white mineral trioxide aggregate on bovine teeth: In vitro research

Yoldaş, SE; Bani, M; Atabek, D; Bodur, H
In vitro assessment of the tooth staining potential of endodontic materials in a bovine tooth model

Dettwiler, CA; Walter, M; Zaugg, LK; Lenherr, P; Weiger, R; Krastl, G
It is unprecedented: Trial management during the COVID-19 pandemic and beyond

Mitchell, EJ; Ahmed, K; Breeman, S; Cotton, S; Constable, L; Ferry, G
Prevalence and risk factors of traumatic dental injuries to permanent anterior teeth among 8–12 years old school children in Egypt

El-Kenany, MH; Awad, SM; Hegazy, SA
Evaluation of root maturation after revitalization in immature permanent teeth with nonvital pulps by cone beam computed tomography and conventional radiographs

Linsuwanont, P; Sinpitaksakul, P; Lertsakchai, T
A prospective clinical study of regenerative endodontic treatment of traumatized immature teeth with necrotic pulps using bi-antibiotic paste

Nazzal, H; Kenny, K; Altimimi, A; Kang, J; Duggal, MS
Color related to ceramic and zirconia restorations: A review

Vichi, A; Louca, C; Corciolani, G; Ferrari, M
Staining potential of neo MTA Plus, MTA Plus, and biodentine used for pulpotomy procedures

Camilleri, J
Traumatized immature teeth treated with 2 protocols of pulp revascularization

Nagata, JY; Figueiredo De Almeida Gomes, BP; Rocha Lima, TF; Murakami, LS; De Faria, DE; Campos, GR
Revascularization outcomes: A prospective analysis of 16 consecutive cases

Kahler, B; Mistry, S; Moule, A; Ringsmuth, AK; Case, P; Thomson, A
Discoloration after regenerative endodontic procedures: A critical review

Žižka, R; Šedý, J; Gregor, L; Voborná, I
Coronal discoloration induced by calcium-enriched mixture, mineral trioxide aggregate and calcium hydroxide: a spectrophotometric analysis

Esmaeili, B; Alaghehmand, H; Kordafshari, T; Daryakenari, G; Ehsani, M; Bijani, A
Comparison of tooth discoloration induced by calcium-enriched mixture and mineral trioxide aggregate

Rouhani, A; Akbari, M; Farhadi-Faz, A
Quantifying coronal tooth discoloration caused by biodentine and endosequence root repair material

Beatty, H; Svec, T
Regenerative potential of immature permanent teeth with necrotic pulps after different regenerative protocols

Nagy, MM; Tawfik, HE; Hashem, AAR; Abu-Seida, AM
Outcome of revascularization therapy in traumatized immature incisors

Mittmann, CW; Kostka, E; Ballout, H; Preus, M; Preissner, R; Karaman, M

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Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial)

Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial)

Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

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Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial)

Clinical and radiographic evaluation of NeoMTA versus conventional white mineral trioxide aggregate in revascularization of non-vital immature permanent anterior teeth (A randomized controlled trial)

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