Management of external invasive cervical resorption of tooth with Biodentine: A case report.

Invasive cervical resorption (ICR) of a tooth is relatively uncommon and the etiology is not very clear. It is sometimes misdiagnosed and can lead to improper management or tooth loss. Correct diagnosis and proper management can result in a successful outcome. The treatment should aim toward the complete suppression of all resorbing tissues and the reconstruction of resorptive defect by the placement of a suitable filling material or some biological systems. One of the most significant developments of the past decade, i.e. the operating microscope used for surgical endodontics, helps the surgeon to assess pathological changes more precisely and to remove pathological lesions with far greater precision, thus minimizing tissue damage. The aim of this article was to show the management of maxillary left central incisor diagnosed with external ICR using Biodentine under dental operatory microscope (DOM).

INTRODUCTION

Invasive cervical resorption (ICR) is uncommon and often aggressive form of external tooth resorption, which may involve any tooth of the permanent dentition.[1] It is defined as a localized resorptive process that involves the surface of root below epithelial attachment and coronal aspect of the supporting alveolar process, namely the zone of connective tissue attachment.[2] Because of its cervical involvement and invasive property, this destructive resorptive defect may lead to the loss of tooth structure. Often, affected tooth may show pinkish discoloration of tooth crown due to resorption of coronal dentin and enamel as highly vascular resorptive tissue becomes visible through this residual structure.

Among the different causes identified, injury and stimulation by sulcular microorganisms in the adjacent marginal tissues is one of the cause[34] and traumatic injuries, orthodontic tooth movement, orthognathic and dento-alveolar surgery, periodontal treatment, and internal bleaching have been reported as predisposing factors for such lesion.[56]

On examination of intraoral periapical (IOPA) radiograph, ICR may represent as a barely discernible radiolucency or may be evident dramatically. The lesions may have well-delineated radiolucencies with irregular borders and sometimes may simulate as caries radiographically.

As initiation of ICR is apical to the epithelial attachment, it is most commonly seen in the cervical area, but it may occur anywhere in the root.[7] Initially at the early stages, it may be somewhat symmetrical but later, asymmetrical nature of larger lesions are more evident.[8]

A successful outcome for such cases generally involve early diagnosis, elimination of the resorption, and restorative management. When ICR is diagnosed, generally, three choices are considerable for treatment:

No treatment with eventual extraction when the tooth becomes symptomatic;

Immediate extraction; or

Access, debridement, and restoration of the resorptive lesion.[9]

Till date, various materials have been promoted to seal the resorptive defect such as mineral trioxide aggregate (MTA), glass-ionomer cement (GIC), calcium enriched mixture (CEM) etc. MTA is a bioactive material that has been used for various endodontic applications since the early 1990s. MTA is indicated for restoring internal and external resorptive defects, horizontal root fractures, sealing communications between the root canal space and external root surfaces, filling root canals of teeth with mature and open apices. MTA has been proved to be biocompatible, stimulate mineralization, and encourage apatite-like crystalline deposits. More recently, other bioactive materials, such as CEM cement, bioaggregate, Biodentine, EndoSequence Root Repair Material (ERRM), and EndoSequence BC Sealer, have also been marketed.[10]

Among the options available, a new bioactive cement, Biodentine (Septodont, St. Maur-des-Fossés, France), can be a valid option since it acts as a substitute for dentin.[1112] It shares both its indications and mode of action with calcium hydroxide, but does not have its drawbacks. When Biodentine was used to seal perforations in the furcal area, it induced the repair of the periodontium and new cementum formation over the material.[1112]

The past decade has revealed the use of the operating microscope for surgical endodontics as one of the most significant developments. The microscope enables the surgeon to assess pathological changes more precisely and to remove pathological lesions with far greater precision, thus minimizing tissue damage.[13]

Therefore, the present case report was about describing the management of maxillary left central incisor with external cervical resorption surgically under operatory microscope using Biodentine.

CASE REPORT

A 23-year-old female patient presented to the Department of Conservative Dentistry and Endodontics, with a discolored upper right and left central incisor (11 and 21). The crown of 21 showed pink hue and there was little swelling in relation to 21 at its labial aspect [Figure 1a].

Figure 1

(a) Preoperative intraoral photograph, (b) Preoperative IOPA radiograph, (c) Cervical resorption defect seen under dental operatory microscope, (d) Sealing of defect with Biodentine under dental operating microscope, (e) Postoperative IOPA radiograph, (f) Eleven months follow-up IOPA radiograph

The medical history of the patient was noncontributory. The patient had noticed color change of related teeth, and it increased over the last 3-4 months. Past dental history revealed that she had undergone trauma 6 years back and teeth remained untreated. The electric pulp test was negative. Periodontal probing depths were physiological at all sites except for the distobuccal surface where sinus tract and the necrotic material were present.

The preoperative IOPA radiographic examination [Figure 1b] revealed an irregular, large radiolucent area in the cervical third of the external root surface at distal aspect of 21 at supra-osseous level. A small external resorptive defect was also noticed on distal aspect of 11. Small periapical radiolucent lesion was detected with both 11 and 21. The clinical diagnosis was irreversible pulpitis with external ICR.

Management

For root canal treatment of 11 and 21 with debridement, curettage, and restoration of the external resorption defect, surgery was the treatment of choice. Consent was obtained from the patient and the procedures were explained to the patient. Under local anesthesia, the access cavities of 11 and 21 were opened on the palatal surface. After working length determination of both teeth, the root canals were biomechanically prepared i.e. cleaning and shaping with manual instruments using #K- files and 3% NaOCl (Parcan, Septodont Healthcare India Pvt. Ltd., India) irrigation. After the root canal systems were debrided, it was rinsed with sterile water and dried with paper points.

As the defect was on the cervical area, a surgical intervention was planned. After giving incision, a triangular full thickness flap was reflected and hemostasis was achieved. A large circular resorptive area was seen clearly from the surgical site containing granulation tissue under the DOM [Figure 1c].

The resorptive area was cleaned by rinsing with alternating solutions of 3% NaOCl (Parcan, Septodont Healthcare India Pvt. Ltd., India) and 17% ethylenediaminetetraacetic acid (EDTA) (Prime Dental product Limited, India)[14] because of property of organic tissue fixation and antibacterial efficacy of NaOCl and some regenerative potential of EDTA such as exposing TGF β-1 from human dentin (to improve clinical outcomes).[15] Granulomatous tissue was removed from the surgical site efficiently through the curettage.

After drying the site, the root canal of 21 was secured by inserting a suitable Gutta-percha (GP) point and the resorptive area was filled with Biodentine (manipulated according to manufacturer's instructions) and contoured as per external root anatomy [Figure 1d]. Also, the small external resorptive defect of 11 was repaired with same material. The material was left for fifteen minutes to achieve the initial setting and relative hardness. After, the setting of Biodentine was confirmed, the root canals of 11 and 22 was properly obturated with GP point after sealer application (Apexit Plus, Ivoclar Vivadent) and access cavity was temporarily sealed with Cavit-G.

Finally, the flap was kept at its original position and sutured with 3-0 black silk suture material and the patient was instructed to report after a week for suture removal. Postoperative IOPA radiograph was taken [Figure 1e].

After suture removal, the patient was subsequently advised for regular follow ups. However the patient reported to the department only after 11 months and was completely asymptomatic on presentation. We performed clinical and radiographic examinations for treated teeth [Figure 1f] and observed that repair of resorption defect was successfully treated with Biodentine.

DISCUSSION

Regarding the treatment of ICR, successful management of each case must be linked to the etiology. A radiographic evaluation is essential to the diagnosis of ICR and the difficulty in distinguishing this lesion from internal root resorption. Use of cone beam computed tomography (CBCT) may be an important diagnostic tool in this regard. This imaging technique may confirm the real extent of resorption and its possibility of communication with the periodontal space.[16]

Different modalities have been suggested by several authors for the treatment of cervical external root resorption. The basic aim of treating ICR is the complete removal of resorptive tissue and the restoration of the defect area.[1417] The present case describes an invasive cervical resorptive defect in which the tooth shows a sign of pulpal and periapical infection and requires root canal treatment followed by sealing the resorptive area with Biodentine using surgical intervention.

The etiological factor for the resorption in the present case seems to be traumatic injury. Since the affected teeth remained untreated for a long period of time, the effect of this would have resulted into resorptive defects. The communication between the resorption defect and the root canal system was large in size, and the defect was treated surgically. Surgical treatment of varying degrees of ICR generally involves periodontal flap reflection, curettage, granulation tissue removal, and restoration of the defect with suitable material, such as MTA,[14] resin-modified GIC,[17] CEM,[10] Biodentine, and repositioning the flap to its original position. The root canal treatment and management of the resorptive defect for this case were performed at the same appointment in order to avoid secondary infection.[1]

Like MTA, a recent endodontic CEM cement was introduced to dentistry in 2006 for endodontic applications. It also has the property of promoting hydroxyapatite formation, stimulating stem cell differentiation and can induce hard tissue formation. It also possesses shorter setting time than MTA and sealing ability comparable to MTA. The clinical uses of the CEM cement are similar to MTA. CEM cement has demonstrated similar results to MTA when used as pulp capping agent, furcation perforation repair, pulpotomy of permanent molar teeth with established irreversible pulpitis, and in management of internal root resorption.[10]

On the other hand, Biodentine has also been promoted as a favorable repair material due to its bioactivity and biocompatibility. Biodentine has setting time of less than 12 min and high mechanical properties with excellent sealing ability. Its property to release calcium ion and enhancing the alkaline environment makes Biodentine more conducive for osteoblastic activity.[1112] Also, calcium and hydroxide ions stimulate the release of pyrophosphatase, alkaline phosphatase, and BMP-2, which favors the mineralization process.[18]

Managing the case with use of DOM, enabled the assess of pathological changes more precisely, and to remove pathological lesions with far greater precision, thus minimizing tissue damage during the surgery and decreased the postoperative patient discomfort.

After the treatment, the patient did not follow the regular visits for check-up, but when returned to the department after 11 months, satisfactory healing was observed in the case. The patient was completely asymptomatic and the radiographic examinations showed healing of the periradicular radiolucency with indication of bone formation.

CONCLUSION

Proper diagnosis, case selection, and its implementation can lead to the successful outcome and long-term retention of the tooth. Although this case report presents a favorable outcome, further studies are encouraged to support the use of Biodentine to fill external ICR defect.

Financial support and sponsorship

Department of Conservative Dentistry and Endodontics, Dr. R. Ahmed Dental College & Hospital, Kolkata - 700 014.

Conflicts of interest

There are no conflicts of interest