[Clinical Guides](https://endo-guide.app/clinical-guides) Clinical Pathway # Regenerative Endodontics: Revascularization of Immature Necrotic Teeth Revascularization is a biologically based option for immature permanent teeth with pulp necrosis, aiming to disinfect the canal and let root development continue. Outcomes are variable and true pulp regeneration is generally not achieved, so case selection and honest expectations matter. Immature necrotic teeth Disinfection over instrumentation Variable outcomes Case selection matters Last updated: July 5, 2026 Reviewed by[Uzm. Dt. Levent Yüksel](https://endo-guide.app/about)DDS · Endodontist[@endoleventyuksel](https://www.instagram.com/endoleventyuksel/)[@endoguideapp](https://www.instagram.com/endoguideapp/) ## Who a regenerative approach suits Revascularization is generally considered for an immature permanent tooth whose pulp has died before the root finished forming. The aim is to disinfect the canal and encourage the tooth's own tissues to continue building the root. ### Immature permanent tooth with pulp necrosis The most established indication is a permanent tooth with a necrotic pulp and an open apex from incomplete root formation, where continued root development would still be valuable. Evidence Kim 2018 Galler 2016 ### Cvek-stage framing The less mature the root, the more there is to gain from continued development. Staging the root against the Cvek description helps weigh a regenerative approach against a barrier technique. Evidence Kim 2018 ### A realistic follow-up plan Because outcomes appear over months to years, an agreed follow-up schedule and a patient or family able to attend reviews are part of sensible case selection. Evidence Galler 2016 ### Where it may fit less well A tooth with near-complete or complete root formation may be better served by conventional root canal treatment or an MTA apical barrier, since there is little further root growth to pursue. Evidence Kim 2018 ## Revascularization vs apexification vs MTA barrier For an immature necrotic tooth the main options are a regenerative (revascularization) approach, apexification, and an MTA apical barrier. The choice turns on how much root growth remains to be gained, restorability, and the follow-up that is realistic. Scenario ### Immature tooth, pulp necrosis, incomplete root, and follow-up is achievable. Often favored A regenerative approach is often weighed to pursue continued root development. Evidence note A systematic review found regenerative treatment and an MTA apical plug had comparable pooled survival and success, with no significant difference. Scenario ### Root formation is near-complete or complete. Often favored Conventional root canal treatment or an MTA apical barrier may be more suitable. Evidence note With little further root growth to gain, the added value of a regenerative approach is smaller. Scenario ### The goal is an apical stop rather than continued maturation, or a regenerative approach is not feasible. Often favored Apexification with an MTA or bioceramic barrier may be considered. Evidence note Apexification does not induce continued root maturation, so the thin root can remain more susceptible to fracture. Scenario ### Tooth is non-restorable, vertically fractured, or reliable follow-up is unlikely. Often favored Extraction with a replacement plan may be discussed. Evidence note Restorability and the ability to review the tooth strongly shape which option is reasonable. ## The two-visit protocol, in outline Revascularization is carried out by a trained clinician, usually across at least two visits. The outline below explains the sequence; it is not an operative protocol, and details vary between published protocols. 1. 1 ### Diagnosis and consent An immature permanent tooth with a necrotic pulp is confirmed, and the variable outcomes and the possibility of crown discolouration are discussed with the patient or family. 2. 2 ### Access and gentle disinfection Under rubber dam, the canal is accessed with minimal or no mechanical instrumentation to preserve the thin dentinal walls, then irrigated gently with lower-concentration sodium hypochlorite followed by saline. 3. 3 ### Intracanal medicament A low-concentration antibiotic paste (double or triple) or calcium hydroxide is placed to disinfect the canal, and the access is sealed for a few weeks. 4. 4 ### Re-entry and irrigation Once symptoms have settled, the medicament is rinsed out and EDTA is used to help expose dentine-derived growth factors. 5. 5 ### Bleeding induction and scaffold Bleeding is evoked from the periapical tissues to fill the canal with a blood clot, or a platelet-rich fibrin or plasma scaffold is used in its place. 6. 6 ### Coronal seal and restoration A bioceramic or MTA barrier is placed over the scaffold and covered with a well-sealed restoration to protect the healing tissue. 7. 7 ### Follow-up Clinical and radiographic reviews over months to years look for resolution of signs, continued root development, and any return of sensibility. ### Visit 1 — disinfect Access, minimal instrumentation, gentle lower-concentration irrigation, and an intracanal medicament left in place for a few weeks. ### Visit 2 — scaffold and seal Medicament removal, EDTA rinse, induced bleeding or a platelet scaffold, and a bioceramic or MTA coronal seal with a definitive restoration. Evidence Galler 2016 Wei 2022 ## Scaffolds and disinfection The scaffold supports the tissue that grows into the canal, and the disinfection materials aim to clean the canal while sparing the cells that make regeneration possible. - A blood clot from induced periapical bleeding is the most established scaffold; platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) are alternatives. - In a triple-blind randomized trial, PRP showed more favourable periapical healing than PRF or induced bleeding, while root lengthening and canal-wall thickening were broadly comparable across the three. - Disinfection is generally emphasized over mechanical shaping, because the thin dentinal walls of an immature root are easily weakened. - Lower-concentration sodium hypochlorite is often chosen to reduce harm to apical stem cells, with EDTA used to expose dentine-derived growth factors. - The intracanal medicament may be a double or triple antibiotic paste or calcium hydroxide, each with trade-offs in disinfection and staining. Discolouration and consent Triple antibiotic paste has been associated with crown discolouration: minocycline is the most commonly implicated cause, but in the same laboratory comparison other antibiotic formulations also discoloured the crown, while double antibiotic paste — which omits minocycline — and calcium hydroxide showed no perceptible colour change. Because discolouration and the prospect of extra appointments matter to patients and families, they are usually discussed as part of consent. ## Outcomes and what success means Reported outcomes come from case reports, case series, cohort studies and a smaller number of randomized trials, so they describe typical patterns rather than a guarantee for one tooth. Success is usually judged on three variable outcomes: resolution of signs and symptoms, continued root development in length and dentine-wall thickness, and, less predictably, some return of sensibility. True regeneration of the pulp-dentine complex is generally not achieved; histological studies show healing that is largely repair derived from periodontal and osseous tissues. In a systematic review and meta-analysis, regenerative treatment and an MTA apical plug had comparable pooled survival, around 98 and 97 percent, and success, around 91 and 95 percent, with no significant difference and a low overall level of evidence. Factors that shape the result - Degree of root immaturity and the amount of remaining apical tissue. - Thoroughness of canal disinfection while preserving the dentinal walls. - Choice and concentration of irrigants and the intracanal medicament. - Quality of the coronal seal and the final restoration. - The cause of necrosis, such as dental trauma, and the follow-up available. ## Follow-up and review Regenerative outcomes develop slowly, so scheduled review is part of the plan. - Clinical and radiographic review is commonly arranged at intervals over the first one to two years and then periodically. - Reviews look for resolution of symptoms, thickening and lengthening of the root, and narrowing of the apical opening. - Some teeth regain a response to sensibility testing, but its absence does not by itself mean the treatment has failed. - If signs of disease persist or return, options such as apexification, conventional treatment, or extraction with a replacement plan can be revisited. New swelling, a sinus tract, increasing pain, or radiographic breakdown warrants reassessment and a change of plan rather than continued waiting. ## What to ask your endodontist 01Is this tooth immature enough for a regenerative approach, or is a barrier technique more suitable? 02What outcomes are realistic here — symptom resolution, continued root growth, or a return of sensibility? 03How likely is crown discolouration, and which medicament will be used? 04How many visits are expected, and over what time? 05What happens if the canal does not respond as hoped? 06How will the tooth be restored and protected afterwards? 07What is the follow-up schedule, and what signs are being watched? 08What are the alternatives, including apexification, conventional treatment, or extraction with replacement? ## Evidence and limitations The evidence base for regenerative endodontics has grown quickly, but it still carries limitations that shape how confidently a single result can be predicted. - Much of the evidence is from case reports and case series; controlled clinical trials remain relatively few. - Success definitions, protocols, and follow-up periods vary between studies, so pooled figures are read cautiously. - Protocols continue to evolve, and position statements are updated as new evidence appears. ## Continue the pathway ### Related EndoGuide pages [Apexification & apexogenesis](https://endo-guide.app/apexification-apexogenesis)[Dental trauma](https://endo-guide.app/dental-trauma)[Vital pulp therapy](https://endo-guide.app/vital-pulp-therapy)[Intracanal medicaments](https://endo-guide.app/medicaments)[Irrigation](https://endo-guide.app/irrigation)[Diagnosis & pulp classification](https://endo-guide.app/diagnosis)[Tooth resorption](https://endo-guide.app/tooth-resorption)[Glossary](https://endo-guide.app/glossary) ## Common questions 01 What is regenerative endodontics? Short answer It is a biologically based approach — also called revascularization or revitalization — for immature permanent teeth with a necrotic pulp. - 01 Rather than removing the pulp and filling the canal, it aims to disinfect the canal and encourage the tooth's own tissues to continue root development. 02 Which teeth are suitable? Short answer It is generally considered for immature permanent teeth with pulp necrosis and incomplete root formation. - 01 Teeth with near-complete or complete roots may be better suited to conventional root canal treatment or an MTA apical barrier. 03 Does it truly regenerate the pulp? Short answer Usually not in the strict sense. - 01 Outcomes are variable, and studies show the healing is largely repair from surrounding tissues rather than true regeneration of the pulp-dentine complex. 04 How does it compare with apexification? Short answer A systematic review found regenerative treatment and an MTA apical plug had comparable survival and success, with no significant difference and low-certainty evidence. - 01 A regenerative approach can allow continued root development, which apexification does not. 05 Can the tooth change colour? Short answer It can. - 01 Triple antibiotic paste has been linked to crown discolouration — minocycline is the most commonly implicated cause, but other antibiotic formulations also discoloured teeth in the same laboratory study — while double antibiotic paste and calcium hydroxide showed no perceptible change, so the medicament choice and the discolouration risk are usually discussed beforehand. 06 How many appointments are involved? Short answer Most protocols use at least two visits — one to disinfect and medicate the canal and another to induce bleeding and place a coronal seal — followed by review over months. 07 What causes an immature tooth to need this? Short answer A common cause is dental trauma, such as luxation or avulsion, which can lead to pulp necrosis before the root has finished forming. ## More in Special situations [Vital Pulp Therapy→](https://endo-guide.app/vital-pulp-therapy)[Apexification & Apexogenesis→](https://endo-guide.app/apexification-apexogenesis)[Dental Trauma→](https://endo-guide.app/dental-trauma)[Tooth Resorption→](https://endo-guide.app/tooth-resorption)[Failed Root Canal→](https://endo-guide.app/failed-root-canal-retreatment)[Endodontic Surgery→](https://endo-guide.app/endodontic-surgery)[Root Canal During Pregnancy→](https://endo-guide.app/root-canal-during-pregnancy) [Previous Vital Pulp Therapy](https://endo-guide.app/vital-pulp-therapy)[Next Apexification & Apexogenesis](https://endo-guide.app/apexification-apexogenesis) [All Clinical Guides (40)](https://endo-guide.app/clinical-guides) ## References 1. [Kim SG et al. Regenerative endodontics: a comprehensive review - Int Endod J (2018);51(12):1367-1388. DOI 10.1111/iej.12954; PMID 29777616](https://pubmed.ncbi.nlm.nih.gov/29777616/) 2. [Galler KM et al. European Society of Endodontology position statement: revitalization procedures - Int Endod J (2016);49(8):717-723. DOI 10.1111/iej.12629; PMID 26990236](https://pubmed.ncbi.nlm.nih.gov/26990236/) 3. [Wei X et al. Expert consensus on regenerative endodontic procedures - Int J Oral Sci (2022);14(1):55. DOI 10.1038/s41368-022-00206-z; PMID 36450715; PMCID PMC9712432](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9712432/) 4. [Torabinejad M et al. Regenerative endodontic treatment or mineral trioxide aggregate apical plug in teeth with necrotic pulps and open apices: a systematic review and meta-analysis - J Endod (2017);43(11):1806-1820. DOI 10.1016/j.joen.2017.06.029; PMID 28822564](https://pubmed.ncbi.nlm.nih.gov/28822564/) 5. [Shivashankar VY et al. Comparison of the effect of PRP, PRF and induced bleeding in the revascularization of teeth with necrotic pulp and open apex: a triple blind randomized clinical trial - J Clin Diagn Res (2017);11(6):ZC34-ZC39. DOI 10.7860/JCDR/2017/22352.10056; PMID 28765825; PMCID PMC5534513](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534513/) 6. [Akcay M et al. Spectrophotometric analysis of crown discoloration induced by various antibiotic pastes used in revascularization - J Endod (2014);40(6):845-848. DOI 10.1016/j.joen.2013.09.019; PMID 24862714](https://pubmed.ncbi.nlm.nih.gov/24862714/) 7. [Duncan HF et al. Treatment of pulpal and apical disease: the ESE S3-level clinical practice guideline - Int Endod J (2023);56 Suppl 3:238-295. DOI 10.1111/iej.13974; PMID 37772327](https://pubmed.ncbi.nlm.nih.gov/37772327/) 8. [Fouad AF et al. IADT guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth - Dent Traumatol (2020);36(4):331-342. DOI 10.1111/edt.12573; PMID 32460393](https://pubmed.ncbi.nlm.nih.gov/32460393/) ## Scope Notice This guide is an educational reference and cannot replace a clinical examination. Regenerative endodontic procedures are planned and carried out by a trained clinician; the outline here is an overview of an evolving, variable-outcome treatment and is not an operative protocol or a substitute for in-person assessment. Scope Written for licensed dental professionals and dental students. It describes general approaches rather than the treatment of any individual patient, and it does not attempt to cover every technique, material or clinical situation. Responsibility for diagnosis, treatment and instrument selection stays with the treating clinician. Where a page reproduces manufacturer values, the current Instructions for Use govern. [Intended purpose and limitations](https://endo-guide.app/intended-use) ![Uzm. Dt. Levent Yüksel](https://endo-guide.app/images/levent-yuksel.jpg) Reviewed by Uzm. Dt. Levent Yüksel DDS · Endodontist Endodontist — DDS, Hacettepe University; endodontics specialty training, Ankara University. 10+ years of clinical experience. Sole author and reviewer of EndoGuide content. [About the author](https://endo-guide.app/about)[Editorial policy](https://endo-guide.app/editorial-policy)[Clinical profile](https://drleventyuksel.com/) --- Canonical HTML: https://endo-guide.app/regenerative-endodontics · Agent guide: https://endo-guide.app/llms.txt