The management of permanent teeth with incomplete root development with compromised pulpal integrity presents a unique challenge. The loss of pulpal vitality before the completion of dentin deposition leaves a weak root more prone to fracture as a result of the thin dentinal walls. Every attempt should be made to preserve the vitality of these immature teeth until maturation has occured. (1)
Pulpotomy is a universally accepted treatment modality for pulp exposures in immature permanent teeth to preserve the vitality of the radicular pulp and to ensure continued root development. (2) Calcium Hydroxide has been the most commonly utilized pulpotomy agent for vital pulp therapy. However, owing to disadvantages such as degradation over time, formation of tunnel defects beneath dentinal bridges and poor sealing , it is slowly losing its popularity as a first choice agent for pulpotomy. (3)
Vital pulp therapy procedures in permanent teeth with incomplete root development have advanced in recent years. Despite Mineral trioxide aggregate has shown promising potential as a pulpotomy agent , it has some drawbacks that include the presence of toxic elements in the material composition (4) , higher cytotoxicity in its freshly mixed state (5)
,high pH during setting (6) , difficult handling characteristics (7) , long setting time (8) , tooth discoloration (9) and high cost. (10)
Consequently, newer calcium silicate-based materials that retain the desirable properties of original MTA but with easier handling and without tooth discoloration have been introduced . Biodentine has several
advantages, as its good sealing ability, adequate compressive strength , a relatively short initial setting time and the promotion of reparative dentin formation with a positive effect on vital pulp cells. (11, 12)
Recently, Regenerative Medicine , especially at the molecular and cellular level has been given great attention towards 'regeneration' instead of 'replacement' approaches. (13) resulting in 'vital pulp therapy' and regenerative endodontics Concepts. (14) In such treatments, clean environment is believed to be a necessity for further success.
Triple Antibiotic Paste (TAP) , is a combination of 3 antibiotics, ciprofloxacin , metronidazole and Minocycline is widely used to achieve a relatively aseptic environment in the radicular space so that the tissue repair and healing can occur. (15)
Promising results have attracted endodontists and general dental practitioners to endodontic regenerative procedures (ERPs). (16) which is considered as a form of a revolution in root canal therapy. (17-19) Now, it has now been taken into account as an alternative method to traditional calcium hydroxide-induced apexogenesis. (20-21)
Recently, the paste used in the regeneration and revascularization protocol. Studies have shown that the paste can eliminate the root canal microorganisms by removing the diverse groups of obligate and facultative gram-positive and gram-negative bacteria , providing an environment for healing. (22,23)
Platelet-rich fibrin (PRF) is a recent innovation in dentistry that has been prepared and used in 2001. (24) It is considered as an autologous healing biomaterial incorporating leukocytes, platelets, and a wide range of key healing proteins in a dense fibrin matrix. (25) PRF serves as a reservoir for the slow continuous release of growth factors that influence and direct the processes of reparative dentinogenesis (26) . Huang et al (27) investigated the effect of PRF on cultured primary dental pulp cells and concluded that PRF can increase dental pulp cell proliferation and differentiation.
Growth factors included in PRF are mitogenic , chemotactic and angiogenic. Therefore, they appear to be critical to the wound-healing process. PRF induces osteoblasts, gingival fibroblasts, and periodontal ligament cells proliferation as a mitogen . Because of growth factors concentrates, PRF promotes wound healing and regeneration which is used in various disciplines of dentistry to repair and regenerate dental and oral tissues. (28-30)
PRF has anti-inflammatory effect and act as an immune regulation mode. It presented as a perfect scaffold in revascularization of immature permanent teeth with necrotic pulps as it enhances cellular proliferation and differentiation. (31,32)
However, there is a limited number of studies reporting on the success of vital pulp therapy for Immature permanent molars. So, the present study will evaluate different pulpotomy modalities used in Immature permanent molars.
