Regenerative and Biologically Driven Apexification in Immature Teeth: A Paradigm Shift in Endodontic Management : A Case Series

Abstract

Background:
Traumatic dental injuries involving immature permanent teeth with open apices and root resorption pose a complex endodontic challenge due to the lack of apical closure, fragile dentinal walls, and ongoing clastic activity. Traditional apexification procedures, though effective, are often time-consuming and yield inconsistent results. The emergence of biologically driven endodontics has shifted the therapeutic paradigm toward regenerative and bioactive approaches that aim to restore both the structure and vitality of the tooth.

Aim:
The present case series aims to highlight the successful management of immature permanent teeth with open apices and root resorption using biologically integrated and pharmacologically modulated regenerative protocols.

Materials and Method

Three cases with similar clinical presentations were managed using customized biomimetic protocols.

• Case 1: A biofunctional plug formed by combining bioactive glass with Platelet-Rich Fibrin (PRF).


• Case 2: Biodentine was incorporated with Concentrated Growth Factor (CGF) to enhance bioactivity.


• Case 3: Injectable Platelet-Rich Fibrin (i-PRF) was blended with bioactive glass to provide a three-dimensional regenerative scaffold.

Additionally, localized application of low-concentration zoledronic acid (0.5–1.0%) was performed within the resorptive cavity to modulate osteoclastic activity and enhance periapical healing.

Results:
All three cases exhibited progressive periapical healing and radiographic signs of hard tissue regeneration over follow-up periods. A consistent pattern of apical closure, arrest of resorptive processes, and re-establishment of periodontal ligament space was observed. The integration of bioactive materials with autologous platelet concentrates provided a biologically favorable environment for tissue regeneration, while localized pharmacological modulation enhanced the stability of healing outcomes.

Conclusion:
The synergistic combination of bioactive scaffolds, autologous growth factors, and localized antiresorptive therapy offers a predictable and biologically sound approach for managing immature teeth with resorption and open apices. This integrative strategy enhances apical sealing, promotes regenerative healing, and restores the structural and functional integrity of the affected teeth.