Regenerative Endodontic Procedures in Immature Necrotic Teeth Current Evidence and Future Directions

Immature permanent teeth with necrotic pulps present a complex challenge due to their underdeveloped root structures and fragile dentinal walls. Conventional treatments such as apexification have provided limited success in promoting continued root development and often leave teeth structurally compromised. Regenerative endodontic procedures (REPs) have emerged as a biologically based alternative, aiming to stimulate tissue repair and root maturation by leveraging the body's own healing mechanisms. The use of stem cells from the apical papilla, in combination with growth factors and suitable scaffolds, offers the potential for reestablishing functional pulp-like tissue. Clinical outcomes have included increased root wall thickness, apical closure, and resolution of periapical pathology, although the quality and consistency of regenerated tissue vary significantly between cases. The biological mechanisms that drive regeneration remain a key focus of research. Successful outcomes rely on the survival of stem cells, the signaling environment within the canal, and the compatibility of materials used during treatment. Irrigants, medicaments, and scaffold types directly affect the viability and differentiation of resident stem cells. Despite encouraging clinical observations, histological analyses frequently reveal tissue formation that differs from native pulp, raising questions about the regenerative process and long-term function. Innovation in this field includes the development of engineered scaffolds, bioactive molecules, gene therapy approaches, and extracellular vesicle-based treatments, all designed to enhance regeneration and overcome variability in patient responses. Emerging evidence suggests that a combination of biological precision and clinical standardization is critical for future success. Regenerative endodontics continues to evolve as a multidisciplinary field integrating biology, materials science, and clinical practice to improve outcomes for young patients with compromised teeth.