Vital pulp therapy shows higher success odds than root canal in immature teeth

ObjectivesThis meta-analysis evaluated whether vital pulp therapy (VPT) provides more favorable outcomes compared with root canal treatment (RCT) in immature permanent teeth with pulpal involvement. Given the pivotal role of pulp vitality in apexogenesis, the study aimed to determine whether biologically conservative interventions offer greater clinical and radiographic success than pulpectomy-based therapies.MethodsA comprehensive search of PubMed, Embase, Cochrane Library, and Web of Science was conducted from inception to the final search date. Eligible studies included randomized controlled trials and comparative clinical cohorts evaluating VPT (partial, cervical, or complete pulpotomy; direct/indirect capping) vs. RCT in immature permanent teeth. The primary endpoint was composite clinical–radiographic success at the longest follow-up. Data were extracted at the tooth level and pooled using random-effects models to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Prespecified subgroup analyses examined the effects of tooth maturity, VPT modality, biomaterial, etiology, and follow-up duration. Meta-regression explored determinants of treatment success, and trial sequential analysis (TSA) was performed to assess the sufficiency of cumulative evidence.ResultsEight studies were included qualitatively, and five contributed tooth-level data (n = 482 teeth). VPT demonstrated significantly higher odds of overall success compared with RCT (pooled OR = 1.37, 95% CI: 1.06–1.78, p = 0.027), with negligible heterogeneity (I2 = 0%). Subgroup analyses showed marked benefit in immature teeth (OR = 3.01, 95% CI 1.43–6.33, p = 0.004), complete/coronal pulpotomy (OR = 2.47, 95% CI 1.11–5.51, p = 0.026), and follow-up ≥24 months (OR = 2.03, 95% CI 1.21–3.41, p = 0.002). Bioceramic-based VPT achieved near-complete success in randomized trials (PMTA/CEM: 98/98 teeth), whereas RCT outcomes plateaued at 79%–98%. Meta-regression identified tooth immaturity, full pulpotomy, and longer follow-up as positive prognostic factors. TSA showed that the cumulative Z-curve crossed the conventional threshold but not the monitoring boundary or required information size, indicating a favorable direction of effect but insufficient evidence for a definitive TSA-adjusted conclusion.ConclusionsVPT was associated with favorable long-term outcomes compared with RCT in immature permanent teeth. However, because the cumulative evidence did not reach the trial sequential monitoring boundary or the required information size, the certainty of this apparent advantage remains limited. Preservation of pulp vitality may support apexogenesis and structural development, but larger comparative studies are still needed before definitive superiority can be concluded.