Endodontic management of invasive cervical resorption: Report of two cases.

Invasive cervical resorption of the tooth is a relatively rare and uncommon phenomenon where the etiology remains idiopathic and unclear, and if not treated may lead to ultimate loss of tooth structure. Advancements in digital imaging have made the clinician to diagnose the pathological changes with great precision. Proper diagnosis and management of this condition is key to the successful outcome. The aim of this article was to elaborate two case reports of invasive cervical root resorption with surgical management using biocompatible restorative material.

INTRODUCTION

Invasive cervical resorption (ICR) is a severe pathological complication, uncommon, and oftenly aggressive form of external root resorption which includes both vital and pulpless teeth.[1] It is defined as localized resorptive process that involves surface of root below epithelial attachment and coronal to supporting alveolar process.[1] Due to the resorptive process, it often creates a pinkish hue as highly vascular resorptive tissue is visible through residual enamel.[2]

Orthodontic treatment seems to be the most common risk factor for ICR followed by physical (orthodontic treatment, segmental orthognathic surgery, transplanted teeth, trauma, bruxism, and guided tissue regeneration) and chemical trauma (tetracycline conditioning of root, intracoronal bleaching, and bone grafting).[2]

Diagnosis is usually done by routine radiographic examination. Heithersay has proposed a clinical classification of ICR depending on the amount of invasion [Table 1].[3]

Table 1

Clinical classification of invasive cervical resorption and prognosis

Radiographic features of lesion may show well-delineated to irregular bordered mottled radiolucencies and sometimes may simulate as caries.[4] However, cone-beam computed tomography (CBCT) is extremely useful in diagnosis and treatment planning.[5]

Histological appearance of the resorbed area has multinucleated osteoclastic cells along the border of dentin surface with highly vascular fibrous tissue as the area contains rarely infective microorganisms, and it is unclear whether the nature of this process is solely inflammatory.[5]

Basic treatment modalities are complete removal of resorptive tissue and conditioning of dentin wall by 90% trichloroacetic acid (TCA) for coagulative necrosis of tissue without damaging the periodontal ligament, and the cavity is restored by restorative material.[5] Various materials have been proposed to seal the invasive cervical resorptive defect such as glass-ionomer cement (GIC), mineral trioxide aggregate (MTA), calcium-enriched mixture, bioaggregate, biodentine, EndoSequence root repair, and EndoSequence BC sealer.[6]

Biodentine may prove to be particularly suitable material for restoring these defects because it may combine acceptable esthetics with the ability to support periodontal ligament (PDL) attachment. The following case reports describe the surgical management of external resorption with the best choice of restorative material biodentine.

CASE REPORTS

Case report 1

A 25-year-old male patient reported to the Department of Conservative and Endodontics with a chief complaint of discolored maxillary left central incisor and pain in relation to maxillary right central incisor. The medical history of the patient was noncontributory. The patient has noticed color change [Figure 1d] and it increased over 5–6 months. Review of dental history revealed a trauma 8 years back and teeth remained untreated. Intraorally, the periodontal probing depths were physiological at all sites except for distopalatal surface where sinus tract and necrosed material were present. Preoperative radiographs revealed an irregular and mottled appearance in the cervical third of the external root surface at distal aspect of 21 [Figure 1a] and widening of the periodontal ligament is seen in relation to 11 [Figure 1b]. To locate the exact position and extension of the defect, CBCT was advised. On interpretation of CBCT, the lesion was supraosseous [Figure 1c]. A diagnosis of pulp necrosis with external cervical root resorption (Heithersay's class III) was made for 21 and chronic apical periodontitis for 11, and therefore, root canal therapy for 11, 21, and surgery for sealing the resorptive defect was planned for 21. Written informed consent was obtained from the patient. Rubber dam was placed. Under local anesthesia (2% lignox, with adrenaline 1:80,000, Indoco Remedies Ltd., Mumbai), access cavity was prepared on lingual surface. After working length determination of both the teeth [Figure 1e], chemomechanical preparation was done till F5 ProTaper universal rotary system and irrigation was performed with normal saline (Baxter Pvt Ltd., Aurangabad) solely, due to the presence of the root canal perforation for 21 and 5 ml of 3% NaOCl (Vishal Dentocare Pvt., Ltd., Ahmedabad, Gujarat) for 11. Both the teeth were obturated using lateral and warm vertical condensation technique [Figure 1f]. The periodontal reparative surgery was performed immediately after the completion of root canal treatment.

Figure 1

(a) Axial plane cone-beam computed tomography analysis of invasive cervical resorption irt 21, (b) coronal plane cone-beam computed tomography analysis, (c) sagittal plane cone-beam computed tomography analysis of invasive cervical resorption irt 21, (d) preoperative intraoral photograph (buccal view), (e) working length determination irt 21, (f) obturation radiograph, (g) mucoperiosteal flap reflection, (h) immediate postoperative radiograph, (i) postoperative 6-month follow-up (palatal view), (j) postoperative 6-month follow-up (buccal view)

A full mucoperiosteal flap was reflected to remove granulomatous tissue which was excavated from the resorptive area [Figure 1g]. The resorptive area was treated with 90% trichloracetic acid (Organo Biotech Laboratories Pvt Ltd., Mayapuri, Delhi) for 30 s. and the resorptive area was filled with biodentine (Septodont, Saint-Maur-des-Fosses, France) and contoured properly and allowed to set for 15 min to achieve initial setting and relative hardness. After radiographic confirmation [Figure 1h], the flap was repositioned and sutured.

Clinical examinations were performed for treated teeth after 6 months. The patient was completely asymptomatic and probing depth was within normal limits, indicating that repair of resorption defect was successfully performed with biodentine [Figure 1i and j].

Case report 2

A 45-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of discoloration in the right maxillary incisor. Medical history was taken which was noncontributory. History of dental trauma was revealed 10 years ago and the teeth remained untreated. On intraoral examination [Figure 2a], periodontal probing depth was 8 mm on the distopalatal side where sinus tract and necrosed material were present. Radiograph depicted an irregular lesion at the cervical and middle third of the tooth. CBCT was advised for further investigation. On interpretation of CBCT, it was supraosseous defect [Figure 2b and c]. As the lesion was subgingival and clinically not accessible, a surgical approach was opted to repair the resorptive lesion. A diagnosis of chronic alveolar abscess with external root resorption was made in relation to 11 [Figure 2d]. Therefore, root canal therapy followed by surgery for closure of resorptive defect was planned for 11.

Figure 2

(a) Preoperative intraoral photograph (buccal view), (b) coronal plane cone-beam computed tomography analysis, (c) sagittal plane cone-beam computed tomography analysis of invasive cervical resorption irt 11, (d) axial plane cone-beam computed tomography analysis of invasive cervical resorption irt 11, (e) working length determination irt 11 (f) master cone placement irt 11, (g) mucoperiosteal flap reflection, (h) immediate postoperative radiograph, (i) postoperative 6-month follow-up radiograph, (j) postoperative 6-month follow-up (buccal view)

Written informed consent was obtained from the patient. Local anesthesia was administered (2% lignocaine). Under rubber dam isolation access cavity preparation was done on lingual surface. Working length was determined [Figure 2e], chemomechanical preparation was done till F5 ProTaper universal rotary system (Dentsply, Maillefer, Switzerland), and irrigation was performed with normal saline solely, due to the presence of the root canal perforation. Master cone selected [Figure 2f] and obturation were done by sectional obturation technique.

After the root canal treatment, a full-thickness mucoperiosteal flap was raised and palatally, and granulomatous tissue was excavated from the resorptive area [Figure 2g]. The resorptive area was treated with 90% TCA (Organo Biotech Laboratories Pvt ltd, Mayapuri, Delhi) for 30 s and the resorptive area was filled with biodentine [Figure 2h]. Radiographic evaluation was done and the flap was replaced and sutured. Periodic evaluation was done for 6 months [Figure 2i and j].

DISCUSSION

The etiological factor in the present case reports is traumatic injury. Hence, the present cases can be classified as Class 3 ICR (the communication between the resorption lacuna and the root canal system was large in size and supraosseous and the defect was treated surgically). It is essential to diagnose ICR and to distinguish the lesion from internal root resorption by radiographic evaluation. CBCT has been advised in these cases to rule out the type, communication, and position of the lesion.

In the presented case, obturation and surgery were performed in one session to avoid secondary infection. After the root canal therapy, full-thickness flap was raised to enhance proper healing and the resorptive area was debrided by using 90% TCA and saline to enhance the adaptation of restorative material.[5]

Periodontal reattachment cannot be expected with composite resin and GIC. To overcome these disadvantages, MTA was introduced which has better periodontal attachment, but in the present case, this is not considered as material of choice because of its long setting time and difficulty in handling.[7]

Biodentine is a new novel calcium silicate cement, and it can be consider as a valid option since it acts as a substitute for dentin with better handling characteristics. Biodentine is one such material which favors repair due to its bioactivity and biocompatibility with a setting time of <12 min and high mechanical properties (compressive strength – 225 MPa) with excellent sealing ability. Its property to release calcium ion and enhance the alkaline environment makes biodentine more conducive to osteoblastic activity. Furthermore, calcium and hydroxide ions stimulate the release of pyrophosphatase, alkaline phosphatase, and BMP-2, which favors the mineralization process.[8]

Periodic checkup once in 6 months was done for both the cases; proper healing of the defect was observed, patients were asymptomatic, and no signs of periradicular pathology were observed during the follow-up period.

CONCLUSION

The multidisciplinary treatment presented here offers a systematic approach in the present case which is always a clinical challenge. However, achieving predictable success in teeth with invasive cervical root resorption is difficult. Prudent case selection and proper execution with knowledge and skills can lead to the successful treatment and long-term success and retention of the tooth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.