Conservative Management of Class 4 Invasive Cervical Root Resorption Using Calcium-enriched Mixture Cement

doi:10.1016/j.joen.2016.05.001

Journal of Endodontics

Volume 42, Issue 8, August 2016, Pages 1291-1294

https://doi.org/10.1016/j.joen.2016.05.001 Get rights and content

Abstract

Class 4 invasive cervical root resorption (ICRR) presents a treatment dilemma in endodontics. The widely accepted treatment options for a class 4 ICRR are to leave these teeth untreated for as long as they are asymptomatic or extraction. This report presents a conservative approach for the management of class 4 ICRR. A 28-year-old woman was referred for root canal treatment of tooth #26. The patient had a history of orthodontic treatment. Radiographic evaluation showed class 4 ICRR that had perforated the root canal space, a radiolucent crestal bony defect, and a periapical lesion. Clinically, a deep (6-mm) probing area was found on the mesial side of the tooth that bled on probing. The tooth was sensitive to percussion. After the treatment options were discussed with the patient, she chose to save the tooth. After complete chemomechanical preparation of the root canal, the entire canal space and perforation area were filled with calcium-enriched mixture cement. No attempt was made to mechanically remove the resorptive lacuna. Twenty four months after treatment, the tooth was functional and asymptomatic, and probing was within normal limits (<3 mm) with no bleeding during probing. Radiographic examination revealed no progression of resorption, osseous healing of the crestal bony defect, and healing of the periapical lesion. Obturation of the root canal space with calcium-enriched mixture cement may be a viable treatment option for an otherwise non-treatable tooth with class 4 invasive cervical root resorption.

Section snippets

Case Report

A 28-year-old female patient was referred from a general dentist for the root canal treatment of tooth #26. The referral letter stated that the dentist started the root canal treatment but could not control the bleeding from the root canal space. The patient's original chief complaint was pain on biting. Although the patient's medical history was noncontributory, a review of the dental history revealed that the patient had completed orthodontic treatment 6 months before the initial visit. The

Discussion

As shown by Heithersay (8), the success rate for the treatment of class 4 ICRR is 12.5%. The traditional technique was to surgically expose the resorptive defect, curette the resorptive lesion, and apply a 90% aqueous solution of trichloroacetic acid to remove all of the resorptive tissues that remained in the dentinal structure. This aggressive regimen was claimed to be 100% successful for ICRR classes 1 and 2 and 78% successful in ICRR class 3 (8). There are several reasons why a surgical

Acknowledgments

The authors gratefully acknowledge the contribution of Dr M. Lamar Hicks, Division of Endodontics, School of Dentistry, University of Maryland Baltimore, for revising this manuscript and for his helpful comments on the article.

The authors deny any conflicts of interest related to this study.

References (37)

S. Patel et al.
External cervical resorption: a review
J Endod
(2009)
L. Neuvald et al.
Cementoenamel junction: microscopic analysis and external cervical resorption
J Endod
(2000)
S. Patel et al.
External cervical resorption associated with the use of bisphosphonates: a case series
J Endod
(2015)
A. Thonen et al.
Occurrence of cervical invasive root resorption in first and second molar teeth of orthodontic patients eight years after bracket removal
J Endod
(2013)
S. Asgary et al.
Comparison of mineral trioxide aggregate's composition with Portland cements and a new endodontic cement
J Endod
(2009)
S. Asgary et al.
The properties of a new endodontic material
J Endod
(2008)
S. Asgary et al.
Periradicular regeneration after endodontic surgery with calcium-enriched mixture cement in dogs
J Endod
(2010)
S. Asgary et al.
Management of inflammatory external root resorption by using calcium-enriched mixture cement: a case report
J Endod
(2011)
M. Roig et al.
Invasive cervical resorption: report on two cases
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2010)
S. Salzano et al.
Conservative nonsurgical treatment of class 4 invasive cervical resorption: a case series
J Endod
(2015)

J. Mente et al.

Treatment outcome of mineral trioxide aggregate: repair of root perforations-long-term results

J Endod

(2014)

K. Siew et al.

Treatment outcome of repaired root perforation: a systematic review and meta-analysis

J Endod

(2015)

M. Parirokh et al.

Mineral trioxide aggregate: a comprehensive literature review—part III: clinical applications, drawbacks, and mechanism of action

J Endod

(2010)

J.R. Kim et al.

Interfacial characteristics of Biodentine and MTA with dentine in simulated body fluid

J Dent

(2015)

N. Sarkar et al.

Physicochemical basis of the biologic properties of mineral trioxide aggregate

J Endod

(2005)

C. Krupp et al.

Treatment outcome after repair of root perforations with mineral trioxide aggregate: a retrospective evaluation of 90 teeth

J Endod

(2013)

I. Tsesis et al.

Prevalence and associated periodontal status of teeth with root perforation: a retrospective study of 2,002 patients' medical records

J Endod

(2010)

A. Nosrat et al.

Regenerative endodontic treatment (revascularization) for necrotic immature permanent molars: a review and report of two cases with a new biomaterial

J Endod

(2011)

Cited by (26)

Artificial Intelligence for Detection of External Cervical Resorption Using Label-Efficient Self-Supervised Learning Method
2024, Journal of Endodontics
The aim of this study was to leverage label-efficient self-supervised learning (SSL) to train a model that can detect ECR and differentiate it from caries.
Periapical (PA) radiographs of teeth with ECR defects were collected. Two board-certified endodontists reviewed PA radiographs and cone beam computed tomographic (CBCT) images independently to determine presence of ECR (ground truth). Radiographic data were divided into 3 regions of interest (ROIs): healthy teeth, teeth with ECR, and teeth with caries. Nine contrastive SSL models (SimCLR v2, MoCo v2, BYOL, DINO, NNCLR, SwAV, MSN, Barlow Twins, and SimSiam) were implemented in the assessment alongside 7 baseline deep learning models (ResNet-18, ResNet-50, VGG16, DenseNet, MobileNetV2, ResNeXt-50, and InceptionV3). A 10-fold cross-validation strategy and a hold-out test set were employed for model evaluation. Model performance was assessed via various metrics including classification accuracy, precision, recall, and F1-score.
Included were 190 PA radiographs, composed of 470 ROIs. Results from 10-fold cross-validation demonstrated that most SSL models outperformed the transfer learning baseline models, with DINO achieving the highest mean accuracy (85.64 ± 4.56), significantly outperforming 13 other models (P < .05). DINO reached the highest test set (ie, 3 ROIs) accuracy (84.09%) while MoCo v2 exhibited the highest recall and F1-score (77.37% and 82.93%, respectively).
This study showed that AI can assist clinicians in detecting ECR and differentiating it from caries. Additionally, it introduced the application of SSL in detecting ECR, emphasizing that SSL-based models can outperform transfer learning baselines and reduce reliance on large, labeled datasets.
Evaluation of Different Techniques and Materials for Filling in 3-dimensional Printed Teeth Replicas with Perforating Internal Resorption by Means of Micro–Computed Tomography
2024, Journal of Endodontics
The aim of this study was to evaluate the filling ability of 2 obturation techniques in 3-dimensional (3D) printed teeth with perforating internal resorption (PIR).
A maxillary central incisor was instrumented and scanned by micro–computed tomographic (micro-CT) imaging. The 3D model was exported in the stereolithographic format and, with the aid of OrtogOnBlender software (Cícero Moraes, Sinop, SP, Brazil), a PIR in the middle third of the root canal was designed. Thirty-two replicas were printed in surgical resin and distributed into 4 groups (n = 8) according to the obturation technique and the material used: 2 groups used the hybrid technique, 1 with Bio-C Sealer (BCS; Angelus, Londrina, PR, Brazil)/gutta-percha (GP; VDW GmbH, Munich, Germany) + Bio-C Repair (BCR; Angelus, Londrina, PR, Brazil) and the other with BioRoot (BR; Septodont, Saint Maur des Fosses, France)/gutta-percha (GP) + Biodentine (BD; Septodont, Saint Maur des Fosses, France), and 2 groups used the incremental technique, 1 with BCR and the other with BD. Postobturation micro-CT imaging was performed to measure the percentage volume of voids and laser confocal microscopy to measure the surface roughness (μm) of the repair cements. Data were compared using analysis of variance and Kruskal-Wallis tests.
Regarding the filling volume in the apical third, the BCS/GP + BCR (89.70 ± 5.15), BR/GP + BD (87.70 ± 8.43), and BCR (84.20 ± 9.00) groups showed the highest percentages compared with the BD group (69.70 ± 6.88) (P < .05). In the area of internal resorption, the BCS/GP + BCR (96.00 ± 2.64) and BCR (95.30 ± 2.93) groups showed the highest percentages compared with the BR/GP + BD group (91.50 ± 1.35) (P < .05). The BD group showed intermediate values that were sometimes similar to the BCS/GP + BCR and BCR groups and similar to the BR/GP + BD group (P > .05). Regarding the quality of the filling in the perforation area, the BCR group showed better results compared with the BD group (P < .001). Regarding roughness, the BCR group (1.66 ± 0.65) showed lower surface roughness compared with the BD group (2.51 ± 0.89) (P < .05).
The capacity and quality of the filling in teeth with PIR were superior with the incremental technique with BCR and the hybrid technique with BCS/GP + BCR.
Guided Tissue Regeneration in Class IV External Cervical Resorption: A Case Report
2023, Journal of Endodontics
External cervical resorption (ECR) is a type of dental resorption that originates from the loss of the cementum's protective layer. The direct exposure of dentin to the periodontal ligament may lead to the invasion of clastic cells through an entry point on the external root surface into the dentinal tissue, causing resorption. Depending on the extension of ECR, different treatments are proposed. Although the literature presents distinct materials and methods for restoring ECR areas, an existing gap is related to care in the treatment of the supporting periodontal tissue. Guided tissue regeneration (GTR)/guided bone regeneration includes the stimulation of bone formation in bone defects using different types of membranes (resorbable and nonresorbable), regardless of its association with bone substitutes or grafts. Despite the benefits of guided bone regeneration, the application of this method in cases of ECR is still under-explored in the literature. Thus, the present case report uses GTR with xenogenic material and polydioxanone membrane in a case of class IV ECR. The success of the present case is related to the correct diagnosis and treatment plan. Complete debridement of resorption areas and restoration with biodentine were effective in tooth repair. GTR contributed to the stabilization of supporting periodontal tissues. The association of the xenogeneic bone graft with the polydioxanone membrane proved to be a viable option for restoring the health of the periodontium.
Surgical management of large-perforated class 4 invasive cervical root resorption: A case report
2023, Journal of Dental Sciences
External Cervical Resorption: A Volumetric Analysis on Evolution of Defects over Time
2023, Journal of Endodontics
Citation Excerpt :
Further studies with larger sample sizes and longer follow-ups can better assess the rate of expansion in ECR lesions. Several case reports and case series articles have reported on different approaches for the treatment of ECR19,23–26. The treatment approach for each case is selected based on the location, size, and extension/perforation of ECR into the pulp space/periodontium1,2.
The aim of this study was to assess the temporal evolution of external cervical resorption (ECR) defects using a volumetric quantification method.
Cone-beam computed tomographic (CBCT) images of patients diagnosed with ECR who chose not to receive treatment and attended recalls were collected. ECR defects were segmented in CBCT images at baseline and recall, and their volumes were quantified. The volumetric ratio of resorption defects/teeth was calculated. Three-dimensional classification of defects at baseline and recall and the prevalence of root surface perforations ≥1 mm were determined. The Wilcoxon matched pairs signed rank test, chi-square test, and linear regression models were used to analyze the data.
Fifteen patients with 20 teeth diagnosed with ECR and an average recall time of 21 months were included. Nine (45%) teeth showed a change in 3-dimensional classification at recall. The volume of resorption defects (P = .0001) and the volumetric ratio of resorption defects/teeth (P = .0001) increased over time. The prevalence of root surface perforations ≥1 mm was higher at recall (n = 17, 85%) compared with baseline (n = 9, 45%) (P = .008). Linear regression models showed significant associations between the resorption defect volume at recall compared with baseline (P < .0001; 95% confidence interval, 0.053–0.081) and the volumetric ratio of resorption defects/teeth at recall compared with baseline (P < .0001; 95% confidence interval, 0.205-0.356). There was no association between the volume of resorption defects at recall with the length of the recall period, sex, or age (P > .05).
When left untreated, ECR defects can increase in size and develop more root surface perforations. ECR has a dynamic nature, and its volumetric increase over time does not result from uniform/linear expansion of the defects.
Intentional Replantation with an Atraumatic Extraction System in Teeth with Extensive Cervical Resorption
2019, Journal of Endodontics
External cervical resorption (ECR) often renders a tooth nonrestorable, especially if it extends deeply within the dental hard tissue. Intentional replantation is sometimes performed as the last resort to save the tooth but may limit conventional forceps extraction because of the high risk of periodontal ligament cell damage or crown fracture.This case report describes the intentional replantation of an upper central incisor with extensive ECR using an axial, atraumatic extraction system to save the otherwise hopeless tooth. The patient was an asymptomatic 37-year-old man with no contributing medical history. The treatment protocol included atraumatic extraction followed by granulation tissue removal, extraoral root canal treatment, and adhesive restoration of the extensive resorption defect. During extraoral manipulation, the utmost care was taken to prevent root surface drying, contamination with dental adhesive, or heat-induced periodontal ligament damage during curing. Two and a half years after replantation, clinical and radiographic examinations revealed normal healing and no symptoms but a slight reduction of bone level compared with the preoperative level and no signs of root resorption or ankylosis. The successful outcome in this case supports the idea of performing intentional replantation with an atraumatic extraction system to save teeth with extensive cervical root resorption and a high risk of fracture during extraction.

View all citing articles on Scopus

View full text

Case Report/Clinical TechniquesConservative Management of Class 4 Invasive Cervical Root Resorption Using Calcium-enriched Mixture Cement

Abstract

Section snippets

Case Report

Discussion

Acknowledgments

J Endod

J Endod

J Endod

J Endod

J Endod

J Endod

J Endod

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Endod

J Endod

J Endod

J Endod

J Dent

J Endod

J Endod

J Endod

J Endod

Case Report/Clinical Techniques
Conservative Management of Class 4 Invasive Cervical Root Resorption Using Calcium-enriched Mixture Cement