Endodontic and surgical management of invasive cervical ...

49 científica dental. vol 12 (special supplement) 2015.

ABSTRACTBackground: Invasive cervical resorp-tion (ICR) is a type of external root re-sorption, characterised by the loss ofhard dental tissue by the action of odon-toclasts. It appears most often in thecervical region of the root surface of theteeth.

Objective: To present a case report de-scribing the protocol for dealing with aninvasive cervical resorption, and litera-ture review of the etiology, diagnosis andtreatment.

Case report: Female patient, 19 yearsold, with no relevant medical history,who came to our clinic due to a pinkishcolouration in the cervico-buccal surfaceof the right maxillary central incisor.

The tooth had no pain on percussion andpalpation. The vitality of the tooth wasnegative. After rigorous analysis, treat-ment was performed which consisted of2 phases: Firstly, a nonsurgical phase fol-lowed by a surgical procedure. The re-construction of the defect was carriedout using glass ionomer cement.

Conclusions: The endodontist needs tounderstand and manage the periodontaland restorative aspects of treating ICR.

After treatment, the patient was satisfiedwith the aesthetic result.

KEYWORDSExternal root resorption; Invasive cervicalresorption.

Endodontic and surgical managementof invasive cervical resorption:Literature review and case report

Case report

Quispe López, NorbertoDen"st, Masters in endo-don"cs, Alfonso X El SabioUniversity (UAX), Masters inperiodon"cs and implants(UAX).

García-Faria García, CarmenDen"st, European specialistmasters in Orthodon"cs(UAX).

Alonso Ezpeleta, Luis OscarProfessor Masters in endo-don"cs (UAX).

Mena Álvarez, JesúsUCM den"st, Director Mas-ters in endodon"cs. Doctorin den"stry (UAX).

Morales Sánchez, AraceliMedical den"st.

Garrido Mar#nez, PabloDen"st, Masters in bucofa-cial prosthesis, Madrid Com-plutense University (UCM).

Correspondence address:Norberto Quispe López,Calle Torres Villarroel número 18,6º. 37005 Salamanca, Spain.Phone no: 660 510431.Email address: [email protected]

Received: September 24, 2014.Accepted (or accepted for publication): October 27, 2014.

Indexed in:- IME- IBECS- LATINDEX- GOOGLE SCHOLAR

Published in spanish Científica Dental Vol. 11. Nº 3. 2014www.cientificadental.es

científica dental. vol 12 (special supplement) 2015. 50

BACKGROUNDRoot resorption is the loss of dental hard tissue as aresult of clastic activity. Reabsorption can be classi-fied as internal or external according to its locationrelative to the root surface. Internal resorption oc-curs within the pulp canal, and tends to be asymp-tomatic; it is usually caused by a chronic infection ortrauma1. Internal resorption is classified into surface,inflammatory and replacement resorption. While ex-ternal root resorption can be divided into progres-sive inflammatory, cervical and replacementresorption.

Invasive cervical resorption (ICR) is a clinical termused to describe a rare form of external root resorp-tion2.

It is seen in most cases as a late complication of trau-matic injuries to the teeth, but may also occur fol-lowing orthodontic movements, periodontaltreatments, whitening and reimplantation. In addi-tion, there is literature supporting unknown etiologyof ICR3.

Clinical presentation of ICR varies considerably. Le-sions can be identified during a routine conventionalradiography (radiolucent area) or by performing aclinical examination, as in most cases it is asympto-matic. Cone Beam Computed Tomography (CBCT) isuseful for the diagnosis and management of ICR, asthe true extent of the defect cannot always be esti-mated by conventional radiography4.

It is characterised by a progressive loss of cementumand dentine with replacement by fibrovascular tissuederived from periodontal ligament.

In early lesions, an irregularity can be seen in the gin-gival contour. In advanced lesions, the crown showsa pink colour, mimicking internal resorption5. Thisdiscoloration is due to vascular granulation tissuethat shows through the thin residual enamel.

Heithersay2,6-8 wrote what are now classic articles inthe literature describing the features, possible predis-posing factors and recommendations for treating ICR.

He divided ICR into 4 categories depending on thedegree of affectation of the mineral tissue.

- Class 1: Small resorption area located in the cer-vical zone with dentin surface penetration.

- Class 2: Well defined resorption, close to the rootcanal showing little or no extension to the rootdentine.

- Class 3: Deep invasion into the dentine, which af-fects both the coronal dentine and extends intothe cervical third of the root.

- Class 4: Extensive resorption which extends be-yond the cervical third of the root.

For Heithersay, treatment8 consisted of mechanicaland chemical debridement of lesions followed byrestoration. For class 1 and 2 lesions, he found a suc-cess rate of 100%; for Class 3 lesions, 77.8% and forclass 4 lesions, a success rate of 12.5%.

Different approaches have been proposed to treatICR. Nonsurgical treatment involves the applicationof 90% trichloracetic acid, curettage of the lesion,endodontic treatment, only if necessary, and restora-tion with glass ionomer cement9.

Surgical treatment varies depending on the degreeof ICR, and consists of lifting a mucoperiosteal flap,curettage of the lesion and restoration of the defectwith composite resin10,11, glass ionomer cement5,ionomer cement with resin12 or mineral trioxide ag-gregate (MTA)13,14.

The aim of this article is to present a case report de-scribing the action protocol for an invasive cervicalresorption as well as a literature review of etiology,diagnosis and treatment.

CASE REPORTFemale patient, 19 years old, with no relevant med-ical history, who came to our clinic due to a pinkishcolouration in the cervico-buccal surface of the rightmaxillary central incisor, 11 (Figure 1). The patient


had no memory of any history of trauma to the af-fected area.

The clinical examination showed the tooth had notbeen restored and there was no decay. A probe in-spection detected a cavitation in the cervico-buccalsurface enamel and bleeding in the area. The toothwas not painful to percussion or palpation. The vital-ity of this after the ethyl chloride test was negative.

Radiographic evaluation consisted of a CBCT (Figure2) and periapical radiography, which revealed a well-defined radiolucent area in the radicular third cervicalroot of 11.

The diagnosis was invasive cervical resorption, Hei-thersay class 3, based on clinical and radiographicfindings.

After studying the case, it was decided to performtreatment in two phases.

The first non-surgical phase consisted of opening andinstrumentation of the root canal with manual K filesto remove the necrotic pulp and disinfect the root

canal. The second surgical stage was to expose anddebride the resorptive defect, perform the root canaland posterior tooth restoration.

After signing the informed consent and local anaes-thesia was given, the root canal was opened on thepalatal face of 11. Heavy bleeding was seen, due tothe link between the root canal and the resorptivedefect.

The operation area covered 23 mm (Figure 3), andwas determined by the apex locator Denta Port ZX (J.Morita Manufacturing) and confirmed radiographi-cally.

The irrigation used was 1.25% sodium hypochlorite,with calcium hydroxide left as intracanal medication.

15 days later under local anaesthesia, the mucope-riosteal flap was opened to expose the entire lesionarea for removal of the granulation tissue by curettes(Figure 4). Once all the granulation tissue was re-moved, the area was bevelled with a diamond hand-piece bur.

The root canal was then irrigated with 1.25% sodiumhypochlorite, before the final irrigation with 1mL of17% EDTA and irrigation of the root canal with 1.25%

Figure 3: X-ray radiograph.

Figure 2: CBCT sagittal sections, where the resorptive extent of the lesionis seen.

Figure 1: Initial clinical appearance, where a pinkish colour is seen in thecervical region of the right central incisor.


sodium hypochlorite. The root canal was preparedusing the Wave One® motor (Dentsply Maillefer) andProtaper� instrumentation system (Dentsply Maille-fer) according to the manufacturer's instructions.The root canal was dried using paper points. The fill-ing technique chosen was side condensation withthe master cone # 50 (Figures 5 and 6). The cementused was AH plus (Dentsply). Once the root canalwas finished, the resorptive defect was sealed usingglass ionomer resin (EQUIA®, GC) (Figures 7, 8 and9). After suturing the flap, the patient received post-surgical indications including a medication regimen(Augmentin 500/125mg 1/8 hours, 7 days; ibuprofen600 mg 1/8 hours, 5 days; chlorhexidine 0.12%).

Follow-up checks were programmed at 7 (to removestitches), 14 and 21 days (Figure 10) and 12 months(Figures 11 and 12).

DISCUSSIONInvasive cervical resorption (ICR) is an uncommonform of external root resorption, which is of interestdue to the irreversible loss of the tooth structure.

In most of the studies reviewed, etiology of the ICRwas not fully established. Although, trauma and or-thodontic treatments top the list of factors causingthis condition15.

There was only one study published2 with a consid-erable number of patients with ICR. This studyanalysed the trigger factors in 222 patients with atotal of 257 teeth undergoing different degrees ofICR. Several predisposing factors were identified,with orthodontics (24.1%) and trauma (15.1%) as themost frequent. Internal tooth whitening was a factor(9.7%) and some cases (16.4%) had no predisposingfactor found.

Cement protects against root dentine resorption. Itis widely accepted that there is a deficit in the pro-tection of root cementum, as it is susceptible tocolonisation by osteoclasts, which resorb the den-tine16,17. The anatomical area most susceptible to ICRis the cementoenamel junction. Microscopic analysisof the cervical region of the teeth showed gaps inthe cement, exposing the dentine and making it vul-nerable to the action of osteoclasts18.

The literature offers other theories to explain the eti-ology of this process. One suggested it is an inflam-matory periodontal process which does not initiallydamage the root surface. However, after eruption ofthe tooth or because of gingival recession, inflam-matory mediators attract resorbing cells to the rootsurface triggering this process19.

However, there are counterarguments where ICR hasbeen described as "aseptic resorptive process"which is secondarily colonised by microorganisms9.

Von Arx20 recently described a series of cases whichshows that ICR occurs in both domestic and wildcats, where it is called Feline Odontoclastic Resorp-tive Lesions (FORL)21. Its etiology, as with ICR, is not

Figure 4: Intraoperative image removing granulation tissue.

Figures 5 and 6: X-ray conometry and final sealing.


entirely clear. Among the predisposing factors forFORL are stress, dietary nutrients, vomiting, irregularcalcium homeostasis, viral infections, and excess vi-tamin D.

In all the clinical cases described by Von Arx, patientswith ICR pathology had been in direct or indirect con-tact with cats. In addition, blood samples were takenfor the neutralisation test for feline herpes simplex

virus type-1 (FHV-1), indicating the transmission ofthe virus to humans.

To establish a good diagnosis of ICR, information

Figure 7: Situation after eliminating all granulation tissue and the cavity isprepared to receive the restorative material.

Figure 8: Restoration with glass ionomer.

Figure 9: Replacement and fixation of the flap.

Figure 11: Follow-up image after 1 year.

Figure 12: Pre-treatment and post-treatment images.

Figure 10: Follow-up image after 21 days (note chlorhexidine staining).


about relevant background, such as trauma, ortho-dontic treatment and teeth whitening is required.Clinical and radiological findings must be consideredas the main criterion. In our case, the patient did notremember having any trauma or orthodontic treat-ment.

For clinical manifestations, the so-called “pink spot"is a sign to consider for diagnosis. Clinically, it is dif-ficult to differentiate the pink stain due to internaldentine resorption and external cervical resorption.Traditionally, the pink spot was considered pathog-nomonic of internal root resorption22; however,these stains are common in ICR and can also befound after intrapulpal bleeding. Thus, differentialdiagnosis cannot be based on only observing a pinkstain.

Radiographic diagnosis especially using CBCT, is anexcellent tool23. Using CBCT, the extent of the resorp-tive defect detection and classification of the apicalperiodontitis can be assessed more accurately, aswell as evaluating root anatomy and detecting rootfractures, among others. In our case, we used CBCTto observe the size, shape and size of the lesion and,in particular, the vestibular-palatal anatomy of thelesion.

Finally, treatment depends on the severity, location,if the defect has perforated the root canal and therestorability of the tooth. Different treatment op-tions are found in the scientific literature, dependingon the nature of ICR and especially in isolated casereports or case series. These alternative treatmentsmay be intentional replantation, guided tissue regen-eration24, eruption with orthodontic forces and re-construction of the lesion (using composite resin,MTA or glass ionomer).

Treatment generally consists of removing the resorp-tion granulation tissue and restoring the defect. En-dodontic treatment may be necessary in caseswhere the ICR has perforated the root canal.

Heithersay6 classified the ICR types according to theextent of the lesion. He also recommended a careful

diagnosis of the case for a good prognosis, and rec-ommended that only classes 1, 2 and 3 should betreated for defects. Class 4 defects have a high prob-ability of failure, due to the extent of the lesion. Ourcase was a Class 3.

To carry out our treatment, the mucoperiosteal flaphad to be lifted to provide full access to eliminatethe root injury by curette.

Heithersay8 recommended the topical application ofa 90% trichloroacetic acid solution, followed bycurettage and restoration with glass ionomer ce-ment. Topical application of trichloroacetic acid pro-duces coagulative necrosis of the tissue.

In our case, the endodontic treatment had to be per-formed in 2 stages. As in our case, bleeding of thepulp and granulation tissue is normally profuse andit obstructs visibility in the initial stages. We left cal-cium hydroxide as intracanal medication25.

After the root canal procedure is finished and all thegranulation tissue is removed, a suitable material toproperly seal the defect is chosen. The materialsused in the scientific literature are glass ionomer ce-ments, MTA, amalgam and composite resin12-14. Wedecided to use reinforced high viscosity glassionomer EQUIA Fil®(GC) to seal the defect in ourcase. This system does not require stratification, iscondensable and not sticky. EQUIA can be used bothin small, medium and large class I, II and V cavities,for both the posterior and anterior segment of theoral cavity, and in abrasions, abfractions and ero-sions.

CONCLUSIONS- A correct diagnosis is of vital importance, to

choose the most appropriate procedure andthereby minimise the possible consequences ofpoor treatment planning.

- Early detection is fundamental to a better suc-cess rate; thus, more comprehensive reviews of


patients with one or more risk factors must bedone.

- ICR treatment depends on the prognosis and ex-tent of the lesion.

- Thanks to the use of different techniques in ourcase, the desired results were obtained. Thus, en-

dodontic treatment is of little use if the lesiongranulation tissue is not removed properly or therestoration appearance is managed poorly.

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