|Year : 2018 | Volume
| Issue : 3 | Page : 228-232
Management of a Class III invasive cervical resorption
Hadi Mohammed Alamri
Department of Restorative Dentistry, Endodontics Division, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
|Date of Web Publication||25-Jul-2018|
Dr. Hadi Mohammed Alamri
Department of Restorative Dentistry, Endodontics Division, Prince Sattam Bin Abdulaziz University, Al-Kharj
Source of Support: None, Conflict of Interest: None
Treating teeth with invasive cervical resorption (ICR) can be challenging, depending on the extent of the defect and its location; the clinician should provide the patient with several treatment options and discuss the advantages and disadvantages of each treatment approach. A thorough clinical and radiographic examination should be done before treatment. This case report presents a case with Class III ICR where controlling the bleeding during treatment was achieved using a different approach than what is documented in the literature; the approach was effective in providing a dry field and isolating the root canal space until the root canal treatment was completed and the surgical repair was performed. The described technique can be used when it is not feasible to provide the surgical and nonsurgical treatment at the same appointment without compromising the treatment objectives.
Keywords: Invasive cervical resorption, root resorption, surgical repair
|How to cite this article:|
Alamri HM. Management of a Class III invasive cervical resorption. Saudi Endod J 2018;8:228-32
| Introduction|| |
The etiology of different types of root resorption remains not well understood. Several types of root resorption have been classified in the literature, but two major categories exist: external and internal root resorption.
External root resorption is mostly seen in cases where loss of the root protective layers has occurred, whether due to trauma, aggressive orthodontic movement, the presence of an impacted tooth, or adjacent tumors, and even in cases of chronic pulpal infections. These are usually found incidentally during routine dental examination since most of the cases are asymptomatic.
Invasive cervical resorption (ICR) is considered a type of external root resorption. In 1999, Heithersay  further classified this type of resorption based on its extent into four classes where Class I is a small resorptive lesion invading the cervical area with shallow penetration into the dentinal structure, Class II is a well-defined resorptive defect penetrating close to the coronal portion of the pulp, in Class III, the resorptive lesion extends to the coronal third of the root, and Class IV is a large and deep resorptive defect extending beyond the coronal third of the root.
Internal inflammatory root resorption is believed to be caused by trauma, chronic inflammation, presence of a crack in the tooth, or invagination. Histologically, the resorptive defect has highly vascularized pulpal connective tissue infiltrated by lymphocytes and plasma cells. Clinically, most cases are asymptomatic; however, depending on the degree of resorption and its location, tooth discoloration may be noticed, and depending on whether the resorption has perforated to root or not, a sinus tract may be detected.
Proper diagnosis and treatment planning are essential to properly manage cases with resorptive defects. Depending on the type of resorption, its location, and extent, the treating dentist may face challenges during the procedure. In this case report, controlling bleeding was a challenge that was dealt with using a new approach that may be used in managing such cases.
| Case Report|| |
A 51-year-old male patient was referred from a general dentist to the endodontics department for assessment and treatment of the right maxillary canine. The patient's main concern was to save his tooth; he also reported some bleeding while brushing his teeth for the past year. The patient does not recall any history of trauma or orthodontic treatment.
Regarding the medical history, the patient has a history of physiologic heart murmurs, he smokes half a pack of cigarettes a day, and he is allergic to penicillin; the patient is not taking any medications.
On examination, there was mild tenderness to palpation and horizontal percussion; the tooth showed negative response to thermal test and positive response to electrical pulp testing. Probing depths around the buccal gingival sulcus were between two and three millimeters; however, probing depths on the palatal aspect of the tooth showed a wide pocket with a depth ranging from four to five millimeters deep with bleeding on probing; the texture of the root surface was irregular. Periapical radiograph showed a metallic Class III restoration on the distal surface of the crown, and an extensive, ill-defined resorptive lesion extending from the cervical to the middle third of the root and covering the whole width of the tooth mesiodistally, and the lamina dura was intact with no signs of a periapical lesion. A cone beam computed tomographic (CBCT) scan was taken using CS 9300 CBCT scanner (Carestream Health, Inc., Rochester, NY, USA), and the scan was viewed using the CS 3D imaging software (Carestream Health, Inc., Rochester, NY, USA) to further evaluate the extent of the resorptive lesion; the CBCT scans showed that the resorptive lesion extended from the cementoenamel junction apically to the end of the cervical third of the root, it involved the whole width of the root mesiodistally, the lesion did invade the root canal space and extended almost halfway the root buccopalatally from the palatal side toward the buccal, and bone resorption palatally following the course of resorption was evident [Figure 1]. The case was diagnosed as pulp necrosis with normal apical tissue, associated with ICR.
|Figure 1: Preoperative cone beam computed tomographic scan showing the extent of resorption and pattern of bone loss|
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The case was discussed with specialists from other disciplines to provide the patient with different treatment options. Orthodontic extrusion to expose the resorptive defect would compromise the crown-root ratio, and the treatment duration was lengthy to the patient, especially that he had a long commute to the clinic. Extraction of the offended tooth and prosthetic replacement was considered an aggressive option, considering that the defect can be accessed. The patient opted for root canal treatment and surgical repair of the resorptive defect.
After anesthetizing the patient and isolating the tooth with a rubber dam, the tooth was accessed and the pulp was extirpated, continuous bleeding was noted, several attempts were made to control the bleeding using epinephrine, calcium hydroxide powder, and curetting the tissue from an orthograde approach; however, none of these methods provided the required hemostasis. To overcome this issue, after establishing the working length with an electronic apex locator using Root ZX II (J. Morita, Kyoto, Japan) and confirming it with a radiograph, the canal was initially instrumented, a paper point was placed in the canal, and under the operating microscope, Cavit G (3M ESPE AG, Seefeld, Germany) was used to seal off the canal from the resorptive lesion and the paper point was used to adopt the Cavit in place while securing the root canal space from being blocked by any excess of the material [Figure 2]a.
|Figure 2: Paper point used to secure the canal and adopt the Cavit G into the resorptive defect (a). Intraoperative photograph showing the surgical repair of the resorptive defect (b). Postoperative periapical radiograph (c)|
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Instrumentation was completed using ProTaper Universal (Dentsply Maillefer, Ballaigues, Switzerland) to size F3. Irrigation during the procedure was done using 2% chlorhexidine digluconate (CHX), and final irrigation protocol consisted of 17% ethylenediaminetetraacetic acid followed by 2.5% sodium hypochlorite (NaOCl). Obturation apical to the resorptive defect was done using gutta-percha and BC sealer (Brasseler USA, Savannah, GA), and coronal to that level as well as the access cavity, the space was sealed with a prefabricated fiber post using ParaPost and ParaCore as a resin cement (Coltene Whaledent, Langenau, Germany).
On the next day and under local anesthesia, a full thickness palatal envelope flap was reflected exposing the resorptive defect, the granulation tissue was curetted and the Cavit G was excavated, thin margins were debrided, and no bone was removed during the procedure as the resorptive lesion was exposed. The resorptive defect was then restored using resin composite [Figure 2]b and a postoperative radiograph was taken [Figure 2]c and the flap was sutured using chromic gut suture [Figure 3]a. The patient was dismissed after he was given the postsurgical instructions.
|Figure 3: Photograph of the surgical site immediately postoperative (a), and 1-week recall (b)|
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The patient was seen a week after the surgery, no signs of infection or inflammation were noted around the surgical site; no pain to palpation or percussion was present [Figure 3]b.
The patient was contacted at 6 months for a recall visit; he mentioned that there is no more bleeding or tenderness during brushing. The patient was asymptomatic, no bleeding on probing was present, and a radiograph was taken [Figure 4]. He was contacted again 6 months later for the 1-year follow-up, but we were unable to reach him.
| Discussion|| |
Although ICR is considered a rare type of resorption and as the etiology is not well understood, a better understanding of the pathologic process has been developing recently. It is believed that trauma, rapid orthodontic movements, internal bleaching, and chronic pulpal infections are the main predisposing factors., Histologic and microscopic studies have found several common findings in cases with ICR; the periodontal ligament and cementum were disrupted at the portal of entry which is usually below the gingival epithelial attachment level, it is from this point of entry where the invading fibrovascular inflammatory gingival tissue initiates the resorption process and progresses toward the pulpal space.,,
Proper treatment planning is essential for every case, and it becomes more important in challenging cases. The use of CBCT to evaluate the location, size, and accessibility of the resorptive defect provided vital information that aided in the treatment planning of this case. The use of CBCT to evaluate teeth with resorption was approved by the joint position statement announced by the American Association of Endodontics and the American Academy of Oral and Maxillofacial Radiology which was updated in 2015. Studies have also shown its accuracy in assessing external and internal resorption.,,
The ultimate goal of treatment for teeth with any type of resorption is to arrest the active resorption process, restore the defect, and maintain the function of the teeth. Moreover, esthetics becomes a goal of treatment when the tooth is in an esthetic zone.
As the accurate diagnosis is essential for proper treatment planning, interpreting the findings of each clinical diagnostic test is critical. In the presented case, the tooth gave a negative response to cold test but gave a positive response to electric pulp testing. It was a false positive response. It is believed that the false positive response to electric pulp testing in such cases is due to the infiltrating fibrovascular gingival tissue invading the resorptive defect.
A major challenge during the endodontic treatment of this case was sealing the root canal space in the instrumentation phase and maintaining a dry field before obturation due to the continuous bleeding from the gingival tissue invading the resorptive defect and into the canal. To overcome this, Cavit G was used to seal the canal temporarily after establishing the working length until the surgical repair was done. The reason for choosing Cavit G was because of its ease of adaptability, stability during application since it is in a putty form, and ease of removal during surgery. Moreover, the fact that it is a material with low toxicity  and has good sealing properties and minimal marginal leakage  made it the material of choice.
In the presented case report, the resorption was large and has perforated the root. In such cases, special attention should be taken during irrigation to avoid NaOCl accident. An alternative irrigant should be considered. In this case, the use of 2% CHX was used until the perforation was sealed. CHX is known to be an irrigant that has similar antimicrobial effectiveness as NaOCl with no irritation to the supporting tissues. However, the main downside of CHX is that it does not have tissue-dissolving capability.,
Several materials can be used to restore the resorptive defect. Bioceramic materials such as mineral trioxide aggregates (MTA) (Dentsply-Tulsa Dental, Johnson City, USA) are considered the material of choice in terms of biocompatibility and preferred in terms of periapical responses.,, However, due to its long setting time, it was excluded in this case. Alternatively, a bioceramic material that could have been used was Biodentine (Septodont, Saint-Maur-des-Fosses, France) which overcomes the long setting time of MTA and is considered as biocompatible as the MTA. Another material that could be used in such cases is Geristore (Den-Mat Corporation, Santa Maria, CA, USA), a resin ionomer, insoluble in tissue fluids and adheres well to tooth structure. Moreover, it was shown in in vitro studies that Geristore is less toxic to fibroblasts than glass ionomer and IRM.
As a clinician, one must be updated with the available products in the market, knowing the chemical, physical, and biological properties of the materials. In addition, understanding the pathological and physiological behaviour of the disease is critical to insure better treatment outcomes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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