Management of an unrepairable root perforation due to inflammatory root resorption: A case report.

Inflammatory root resorption (IRR) is an irreversible/pathological process caused by the odontoclastic cell activity of dental pulp or periradicular tissues, resulting in the loss of hard dental tissues. If not timely diagnosed and properly managed, the resorption process will persist, and consequently, the root canal may begin to communicate with periodontium, and root perforation (RP) could sequentially occur. Detection of small RPs is difficult using periapical radiography; nevertheless, medium-size/huge RPs can be easily detected, specifically with cone-beam computed tomographic (CBCT) imaging. Root perforations should be managed with non-surgical and surgical methods; with large perforations showing poor prognosis, since they are difficult to be efficiently sealed. Consecutively, the bacteria and their by-products can easily move from the root canal(s) to the surrounding regions.

A 35-year-old man was referred with an active draining sinus tract over the maxillary right canine. The patient reported a history of orthodontic treatment four years ago. Clinical examination revealed that the upper incisors had been lingually splinted; while the involved tooth disclosed no mobility, demonstrated normal probing depths and had a compromised coronal restoration. Initial diagnostic radiographs (periapical/CBCT imaging) unveiled a huge root perforation and a large radiolucency (10 mm) within the root extended toward the mesial aspect, extensively perforating the buccal cortex (Fig. 1A–E). To manage the draining sinus tract, it was decided to retreat tooth #11 via a nonsurgical orthograde approach with initial use of intracanal medication (Fig. 1F). However, after two-week application of calcium hydroxide, the drainage continued (Fig. 1G), and therefore, surgical retreatment was arranged. After coronal filling of the tooth with resin-based dental composite and surgical approach, the granulation tissues were removed. To prepare the apical and coronal fragments of the root canal through the mid-root window, ultrasonic retrotips were employed. Using calcium-enriched mixture (CEM) cement (BioniqueDent, Tehran, Iran), the two root canal spaces were filled/sealed (Fig. 1H). Ten days postoperatively, the sinus tract disappeared and the patient reported no complains/symptoms. At the three-year recall, the tooth was clinically functional/symptom-free. Periapical radiography and CBCT imaging (Fig. 1I–K) revealed complete healing of the lesion and thorough bone formation.

Figure 1

Periapical radiographs and cone-beam computed tomographic (CBCT) images of the case. (A) Initial periapical radiograph of the maxillary right canine shows previous endodontic treatment and severe inflammatory root resorption in the mid-root. (B–E) Preoperative CBCT images clearly demonstrate the destructive nature of the endodontic lesion which has perforated the mid-root as well as the buccal cortex. (F) The radiograph shows applying the calcium hydroxide as an intracanal medication; however, (G) the sinus tract was actively discharged as confirmed by gutta-percha tracing. (H) The immediate post-surgical radiograph reveals the filling/sealing of the apical fragment of the coronal segment of the root canal and the coronal fragment of the apical segment of the root with calcium-enriched mixture (CEM) cement. (I–K) Three-year follow-up radiograph and CBCT images revealed complete resolution of endodontic lesion, bone formation, and re-establishment of the periodontal ligament.

To preserve teeth in which fast/destructive IRR has been progressing toward RP, the perforation site should be immediately cleaned/repaired. The main objective of treatment is to control/prevent the spread of endodontic infection to the periodontium via antibacterial protocols and repair the perforation site. Using calcium hydroxide as intracanal medicament has demonstrated successful results in many case reports; however, there is a growing body of evidence questioning its effectiveness, especially in retreatment cases; e.g. the present study. In addition, in the current case, due to the severe destruction of root walls, the repair of perforation was impracticable. Therefore, using the perforation window, the apical fragment of the coronal segment of the root canal as well as the coronal fragment of the apical segment of the resorbed root were innovatively prepared and then, filled/sealed with CEM cement, as a perforation repair biomaterial. Complete healing of the lesion, in this case, can confirm the effectiveness of the introduced innovative approach using CEM cement in management of huge RPs in which repair is impractical.

Declaration of competing interest

The author has no conflicts of interest relevant to this paper.