Regenerative endodontic procedures (REP) are biologically based procedures, designed to replace damaged structures, including dentine and root structures, along with the cells of the pulp-dentine complex.¹ The three essential elements in any regenerative procedure include stem cells, scaffold, and growth factors.²

Human amniotic membrane is an avascular tissue of fetal origin. It is the innermost lining of the human placenta, which is disposed after the baby is born.³ A thick basement membrane together with an avascular stromal matrix constitutes the structural aspect of amniotic membrane. It contains two types of cells – embryonic ectodermal-derived human amnion epithelial cells and embryonic mesodermal-derived human amnion mesenchymal stromal cells. Both the cell types share similar immune phenotype and are capable of differentiation into major mesodermal lineages.⁴ The human amniotic membrane also acts like a scaffold for cell proliferation and differentiation.⁵

Thus, lot of attention has been paid toward the use of amniotic membrane for transplantation and regeneration procedures. The preserved human amniotic membrane has been already tried in various areas of medicine and dentistry to regenerate the lost tissues and to accelerate repair.⁶ However, there is not much documented literature, where amniotic membrane has been used for REP. This case report describes the clinical and radiographic findings of a successful REP of a nonvital immature permanent tooth with apical periodontitis, using amniotic membrane.

An 8-year-old female patient reported with the chief complaint of trauma to the upper front teeth 1 day ago due to a fall from the bed while playing at home. No significant findings were present on extraoral examination.

Intraoral examination revealed mixed dentition status with an Elli's Class I fracture of tooth 11 and Elli's Class II fracture of tooth 21. Both the teeth were tender on vertical percussion. Radiographic examination revealed an open apex in relation to teeth 11 and 21 without any signs of periapical pathology Figure 1a,Figure 1b,Figure 1c. Thus, Type III glass ionomer cement (GC Corporation, Tokyo, Japan) was placed on the fractured incisal edges of 11 and 21.Figure 1

Preoperative cone-beam computed tomography (a) Sagittal view of tooth 11 showing a wide-open apex of diameter 3.22 mm. (b) Axial view of teeth 11 and 21. (c) Coronal view of teeth 11 and 21.

Existing literature on endodontic regeneration of immature permanent teeth, successfully documents the use of blood clot, platelet-rich plasma, and platelet-rich fibrin as different approaches toward the root development and apex closure. However, these methods have few disadvantages, namely invasiveness in the procedure, associated discomfort while inducing bleeding/withdrawal of the blood, time and difficulty involved in the preparation, and relatively high treatment cost.⁸

Suresh et al.⁹ reported the first case, where REP was performed in a nonvital immature permanent central incisor using human amniotic membrane. At the end of 3 years, they found approximately 78%–86% reduction in the volume of periapical lesion size, increase in canal width, as well as positive response to pulp sensitivity tests. Even in the present case, we observed gradual and significant increase in the root length and apex closure at 3^rd, 6^th, 9^th, and 12^th month follow-ups.

The regenerating ability of the amniotic membrane can be explained in manifold. The cells of amniotic membrane are pluripotent in nature. The membrane acts as an ideal scaffold to encourage migration, adhesion, and differentiation of epithelial cells, while preventing their apoptosis. The amniotic membrane cells are also capable of producing multiple growth factors including vascular endothelial growth factor (VEGF) and insulin-derived growth factor. These growth factors favor the formation of granulation tissue and the epithelialization leading to neovascularization.¹⁰

The criteria that we chose for case selection and the procedure followed were similar to that of any other regeneration case. We used triple antibiotic paste for root canal disinfection, due to its effectiveness in combating the existing diverse microflora present in the necrotic pulp, root canal dentine, and periapical lesions.¹⁰ MTA was used to provide a tight coronal seal, as it also has an added advantage of promoting the growth of stem cells through the release of signaling molecules.¹¹

Amniotic membrane is cost-effective and easy to handle. Disinfected amniotic membrane obtained from a consented donor following an elective cesarean delivery, is the ideal choice, and it can be even preserved for future use.¹² Although it is a human-derived tissue, it carries a negligible risk of infection or immunogenicity.¹⁰ We used processed and stored membranes, which were available for research purpose. These membranes are ultrathin in thickness due to which it can be easily molded to any root canal irrespective of its shape and configuration. In vitro, it has shown unaltered strength and shape when soaked in sterilized physiologic saline solution for 1 month. However, the biodegradable rate after a month is unknown.³

The amniotic membrane is a promising material to be used for revascularization of immature permanent teeth. When used for the same, it results in continued root development, thereby indicating the successful revascularization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.