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CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 3  |  Page : 139-143

Intracanal management of a post traumatic perforative invasive cervical root resorption using calcium enriched matrix cement


1 Department of Endodontics, Iranian Center For Endodontic Research, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Endodontics, Prosthodontics, and Operative Dentistry, School of Dentistry, University of Maryland, Baltimore, MD, USA
3 Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Date of Web Publication20-Nov-2013

Correspondence Address:
Mahta Fazlyab
Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Evin, 1983963113,
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-5984.121507

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  Abstract 

Invasive cervical root resorption (ICR) is a consequence of a resorptive soft-tissue penetrating into dentin that starts below the gingival attachment and tends to be asymptomatic unless dental pulp involvement. Prompt diagnosis is the key to retention of the involved tooth. Treatment procedure includes non-surgical elimination of the resorptive soft-tissues and restoration of the cavity. In case of pulp involvement, endodontic treatment is indicated. This is a report of a non-surgical intra canal treatment case in a maxillary central incisor, which involved the pulp and was successfully treated with calcium enriched mixture (CEM) cement. Based on favorable long-term treatment outcomes, CEM cement may be a promising biomaterial in treatment of ICR cases.

Keywords: Calcium enriched mixture, cervical resorption, endodontic, root resorption


How to cite this article:
Asgary S, Nosrat A, Fazlyab M. Intracanal management of a post traumatic perforative invasive cervical root resorption using calcium enriched matrix cement. Saudi Endod J 2013;3:139-43

How to cite this URL:
Asgary S, Nosrat A, Fazlyab M. Intracanal management of a post traumatic perforative invasive cervical root resorption using calcium enriched matrix cement. Saudi Endod J [serial online] 2013 [cited 2019 Nov 19];3:139-43. Available from: http://www.saudiendodj.com/text.asp?2013/3/3/139/121507


  Introduction Top


Invasive cervical root resorption (ICR) is a type of external root resorption, which usually occurs below the epithelial attachment and the coronal aspect of the supporting alveolar process. [1] ICR has several etiologic factors including orthodontic treatments, trauma, intracoronal bleaching, surgical procedures and periodontal therapies. [2],[3] The resorptive condition is often asymptomatic and is diagnosed by radiographic examinations. A pink spot in the cervical region of the tooth is usually the clinical sign of the ICR and is the result of a highly vascular granulation tissue becoming visible through the resorbed dentin. [1]

Based on the location and extension of the resorptive lesion, Heithersay classified ICR into four classes: Class 1 represents shallowest penetration into the dentin near the cervical area; Class 2 represents a well-defined resorptive lesion that has penetrated close to the coronal pulp chamber, but has little or no extension into the radicular dentin; Class 3 represents a deeper invasion of the dentin that involves the coronal dentin and extends into the coronal third of the root; Class 4 represents a large invasive resorptive lesion that has extended beyond the coronal third of the root. [4] This classification enables the clinician to make a decision regarding treatment of cervical resorption. Endodontic treatment might be necessary in some Class 2 lesions with involved pulp and almost all Class 3 lesions when pulpal involvement has occurred. The Class 4 lesions usually lead to tooth extraction as the extensive nature of Class 4 lesions makes treatment difficult. [2],[3]

Ideally, the treatment protocol for ICR should arrest resorptive process, prevent further resorption, restore damaged root surface and in cases of pink spot, improve the esthetics of the tooth. [3] These treatments include treating the ICR by an internal approach in cases of pulp involvement [5] or an external approach which is done by surgical exposure of the lesion and debridement of the resorptive tissue, followed by restoration. [4] A non-surgical technique that involves the topical application of a 90% solution of trichloroacetic acid (TCA) to the resorptive tissue followed by curettage, has been offered as well. [4] Some articles report a successful combination of these approaches. [6] Root canal therapy (RCT) is merely indicated in cases of pulp involvement and tooth's becoming symptomatic. [2],[3]

Calcium enriched mixture (CEM) cement is a newly introduced water-based tooth colored endodontic cement, which is an alkaline biomaterial and releases calcium and phosphorus ions during and after setting. [7],[8] When used as a retrograde filling or a perforation repair material, [9] the biologic responses of periodontium to the CEM cement were comparable with mineral trioxide aggregate (MTA), which is the preferred biomaterial. [10] Case studies demonstrate that CEM cement is a reliable biomaterial for being used as an apical plug in open apex immature teeth or mature teeth with apical resorption. [11] CEM is proved to be hard tissue inductive; dentinogenic, cementogenic and osteogenic. [12] In addition, CEM cement has the similar sealing ability [13] and biocompatibility to MTA. [14] A case report with long-term follow-up showed that CEM cement has the ability to cease inflammatory external root resorption and might be a useful obturation material for such cases. [15]

This case represents a successful management of a Class 3 ICR by a mere intracanal approach and repair of the perforation site with CEM biomaterial.


  Case Report Top


A 35-year-old male was referred to our clinic with a history of impact trauma to the lower and upper anterior teeth 2 years before the initial visit. The patient's records showed that after trauma, he had been visited by a general dentist who didn't do any intervention. Patient's chief complaint was swelling and pain in mandibular anterior teeth and prolonged pain in the anterior side of the maxilla after consumption of warm drinks. He also reported a discoloration in his upper left incisor (#21) that had started some months earlier. Clinical examinations revealed that three lower incisors (mandibular left lateral incisor #32, left central incisor #31 and right central incisor #41) were not responsive to cold test with Endo-Frost cold spray (Roeko; Coltene Whaledent, Langenau, Germany) and were sensitive to percussion and palpation. Considering the history of impact trauma and patient's complaint, we also examined anterior maxillary teeth. None of the maxillary incisors were sensitive to percussion and palpation while heat testing applied separately on each incisor, caused severe pain in #21. Probing depths of maxillary incisors were normal (<2 mm); however, probing on the mesiopalatal side of #21 caused profound bleeding. Moreover, assessment with an explorer revealed a cavitated lesion in the same tooth just below the cervical margin located mesiopalatally. The dentin underlying the lesion seemed sound under the explorer tip.

Orthoradial radiographs showed a radiolucent lesion in periapical area of mandibular incisors. Meanwhile, a radiolucent resorptive lesion was discovered in the mesial-cervical region of #21 [Figure 1]a. Based on the patient's history, clinical examinations and nature of the lesion, besides the location and extension of the radiolucent lesion to the coronal third of the root of #21, our concluding diagnosis was a Class 3 invasive cervical resorption, which had involved the pulp and caused symptomatic pulpitis. Furthermore, the absence of sensitivity to percussion and palpation for this tooth besides the lack of periapical periodontal ligament (PDL) widening on radiographs, revealed a normal periapical area for the upper left incisor. Also, for the mandibular incisors we assumed that necrosis of #32, #41 and #42, was a consequence of the previous trauma. The diagnosis was pulp necrosis and a phoenix abscess forming in a pre-existing chronic apical periodontitis, which necessitated endodontic treatment. Patient was informed about the problem of cervical resorption in his upper left central tooth and necrosis of the lower incisors. All consequences and prognosis of the treatment were explained for the patient. We decided to do RCT on the lower incisors and an exploratory access cavity in #21 through which the extension of the lesion could be assessed and probable debridement and restoration of the resorption lacuna synchronous with RCT, made up the treatment plan. We also kept the probable need for full mucoperiosteal flap in mind.
Figure 1: (a) Pre-operative periapical radiograph of the left maxillary central incisor. Note the invasive cervical resorption in mesial-cervical surface of the tooth, which extends to the coronal third of the root; (b) immediately after root canal treatment and filling the cavity with calcium enriched mixture cement; (c) a 2-year follow-up radiography that reveals ceasing of the resorptive process; (d) 5 years after initial treatment. The
tooth was functional and there was no sign of further resorption in the radiograph. Note the up-growth of mesial marginal alveolar bone on the root surface and CEM cement (red arrow); and (e) 5 years after treatment the absence of tooth discoloration is obvious


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After local anesthesia and rubber dam isolation, access cavity was prepared using a diamond coated fissure bur (Diatech, Heerbrugg, Switzerland). The root canal was cleaned and shaped with hand K-files (Dentsply Maillefer, Tulsa, Okla, USA) and was copiously irrigated with 5.25% NaOCl during instrumentation. Obturation of the canal was done using cold lateral condensation of Gutta-percha (Ariadent, Tehran, Iran) and sealer (Pulp Canal Sealer, Kerr, MI, USA). After obturating the canal, the resorptive lesion exposed through the access cavity was debrided and cleaned by alternating use of a low speed carbide round bur (Diatech, Heerbrugg, Switzerland) and copious irrigation with 5.25% NaOCl. Then CEM cement (BioniqueDent, Tehran, Iran) powder and liquid were mixed according to manufacturer's instruction and was inserted in the resorptive area. The mixture of the CEM cement was gently adapted to the dentinal walls by using a cotton pellet. At the end, the access cavity was temporarily restored with Coltosol (Asia Chemi Teb Co., Tehran, Iran) [Figure 1]b. A day after treatment, the temporary restoration was removed and the tooth was permanently restored with a prefabricated post-cemented in the canal and composite resin (3M ESPE, St. Paul, USA).

For the upper incisor, patient was recalled for clinical and radiographic follow-ups at 12, 24, 36, 48 and 60 months after the operation. Clinically, the tooth was functional without sensitivity to percussion and palpation and the periodontal status of the tooth was normal (i.e., probing depth <2 mm without bleeding on probing) in all follow-up sessions. A 2-year follow-up radiograph showed that the cervical resorption had ceased and there was no sign of reactivation [Figure 1]c. A 5-year follow-up period did not reveal any discoloration in the tooth. In addition, the up-growth of the mesial marginal alveolar bone on the outer surface of the resorbed root and CEM cement was obvious [Figure 1]d and e. Since the other maxillary incisors probably had the same trauma, they are believed to be prone to ICR and have been on a regular follow-up since then.

For the mandibular incisors, RCT was done during the same session with hand K-files (Dentsply Maillefer, Tulsa, Okla, USA) and 5.25% NaOCl irrigation. Obturation of these teeth was postponed for 1 week and during this time period, calcium hydroxide was used as intracanal medication (calcium hydroxide powder [Golchay, Tehran, Iran] was mixed with 0.2% chlorhexidine [Behsa Pharmaceutical Company, Tehran, Iran] to prepare a thin mixture). After 1 week, canal obturation and restoration of the access cavity was done [Figure 2]a. A 1-year follow-up radiography and clinical assessment revealed healing of the large periradicular lesion by osseous replacement and normal gingival tissues [Figure 2]b and c.
Figure 2: (a) Root canal treatment of three necrotic mandibular incisors; and a 1-year follow-up (b) radiography shows healing of the lesion; (c) photography shows normal tissues surrounding the incisors

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  Discussion Top


This was a report of an ICR non-surgical intracanal treatment case in a maxillary central incisor that had caused pulpal symptoms. Heithersay [4] and Patel [3] stated that in case of pulp involvement, in Classes 1-3, the root canal should be non-surgically accessed and occluded with Gutta-percha point. Therefore, the repair of the resorptive defect might be done without blocking the root canal with filling material; then endodontic treatment might be completed. Heithersay [4] reported a 100% success rate for such treatment cases of Class 1 and 2 cervical root resorption, 79% for Class 3 and only 12.5% for Class 4. He concluded that apical extension of the resorptive lesion is an important factor in the prognosis of the treatment. Therefore, while he believes that Classes 1-3 are successfully treated, Class 4 lesions are deemed untreatable due to the extensive nature of the lesion. Although in many articles surgical intervention have been advocated, [2],[3] there are reports and long-term follow-ups of many internally treated cases of Class 3 lesions with successful outcomes. [5],[16] In addition, for most of the patients any treatment protocol containing surgery, sounds unpleasant and an alternating non-surgical approach-if present-is preferred by them. Long-term successful outcome (5 years) in the present case brings evidence showing that Class 3 ICR lesions can be treated by an internal approach and there might be no need for surgical intervention in similar cases.

Complete debridement of resorptive tissue is an important part in treatment of ICR. [2],[3] Heithersay [2] suggested use of 90% TCA as a caustic agent which can penetrate resorptive lacunae and cause coagulation necrosis in resorptive tissues. Because of its caustic effects, adjacent tissues must be protected before application. In addition, TCA-treated dentin is severely demineralized and should be eliminated before restorative procedures, especially dentin bonded restorations. [16] On the other hand, others have reported successful use of ultrasonically activated 5.25% NaOCl with 17% ethylenediaminetetra-acetic acid (EDTA) [5] or mechanical debridement only. [17],[18] In the presented case we debrided the lesion mechanically using round bur and 5.25% NaOCl irrigation.

In the external approach, the clinician has direct access to the resorptive lesion and treatment of choice in such cases is complete debridement of the lesion followed by dentine-bonded restorations. [19] Besides, in the internal approach if the penetration sites to the PDL space are small and the clinician is able to achieve hemostasis, dentine-bonded restorations are applicable. [16] Several case reports state that MTA might be a suitable biomaterial to restore the resorptive cavity in the internal approach. [5],[17] MTA is a biocompatible material with cementogenic and osteogenic properties, which can effectively seal the communications between PDL and pulp space. [20] Because of these favorable features, MTA is the material of choice in repair of perforations. [10] On the other hand, like MTA, CEM cement is a biocompatible material, [14],[21] which produces similar biological responses in contact with PDL tissue, especially in inducing the cementum-like tissue. [9] Meanwhile, CEM cement is a tooth-colored biomaterial [8] which, unlike MTA, [10] does not cause tooth discoloration and might be a favorable material for being used in anterior teeth as in the present case.

MTA is a bioactive material which releases calcium ion in aqueous environments. This calcium ion reacts with environmental phosphorus and produces hydroxyapatite crystals on the surface of MTA [22] and MTA-dentin interface. [23] This bioactive reaction is assumed as the basis for biocompatibility, hard-tissue induction potential and sealing ability of MTA. On the other hand, CEM cement has an insidious reservoir of calcium and phosphorus ions, which enhances the bioactive reactions on its surface even in normal saline, which lacks phosphorus ion, the phenomenon, which was not seen on the surface of MTA. [22] This can partly explain the sealing ability, [13] biocompatibility [14],[21] and hard tissue induction potential [9],[24],[25] of CEM cement in other studies and also the up-growth of crestal alveolar bone on the surface of CEM cement in the present case.

One of the probable hypotheses for ICR is that after injury to the external root surface and cementum, penetration of bacteria from gingival sulcus to the patent dentinal tubules causes the ICR to progress. [26] As a result, osteoclast-promoting substances are released by sulcular bacteria and inflammatory cells, which can trigger and promote the resorption process. A chemical way of arresting or preventing this clastic attack on the root surface is to change the pH of the root surface and dentinal tubules to an alkaline pH, which can interfere with clastic cell activities. [19] CEM is an alkaline cement (pH > 10.5) [8] with comparable antibacterial properties compared to calcium hydroxide. [27] Therefore, CEM cement has the necessary features as a suitable material to stop the resorptive process.

The successful long-term treatment outcomes of the present case demonstrate that CEM cement may be a suitable biomaterial in management of ICR in an intracanal approach. Meanwhile, more studies on biological mechanisms by which CEM cement ceases PDL inflammation and induces hard tissue production are necessary.

 
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