Regenerative Endodontics Vs Apexification In Bilateral Premolars

This case-controlled study compares regenerative endodontic procedures (REPs) and apexification in contralateral mandibular premolars (#35 and #45) of a single pediatric patient, eliminating interindividual variability to objectively evaluate treatment outcomes. A 9-year-old male presented with bilateral mandibular premolars diagnosed with apical periodontitis secondary to central cusp fractures. Tooth #45 underwent REPs with blood clot induction, whereas tooth #35 received apexification (apical barrier + gutta-percha obturation) due to severe trypanophobia. At 24-month follow-up, clinical and radiographic assessments revealed comparable root lengthening and apical closure in both teeth. Radiographically, the REP-treated #45 demonstrated relatively regular canal development with apical diffuse calcification, contrasting with the irregular calcification pattern observed in the apexification-treated #35. No significant difference in root length development was observed between the two teeth. While REPs are widely regarded as superior for achieving comprehensive root maturation, this study demonstrates equivalent longitudinal root development under controlled inflammatory conditions. The findings align with emerging evidence that implicates processes mediated by Hertwig’s epithelial root sheath and stem cells from the apical papilla as critical drivers of apical closure, independent of therapeutic approaches. Notably, the advantage of REPs resides in their capacity to generate structured calcification patterns, which may enhance biomechanical resilience. Both REPs and apexification effectively promote root development in immature teeth. Clinicians may consider apexification as a viable alternative when REPs are contraindicated. This case provides further clinical evidence that root lengthening may not be determined by therapeutic approach.