CLINICAL RESEARCH
Ahmed Jebril, BDS,
Sanaa Aljamani, BDS, MFDS
RCS (Ireland), MEndo RCS
(Edin), DDSc, and Fadi Jarad,
BDS, PhD, MFDS RCS (Eng),
MEndo RCS (Ed), FDS RCS (Ed
Restorative Dentistry), FHEA, ITI
Fellow
SIGNIFICANCE
ECR is a complex, aggressive,
and uncommon form of
external resorption. The
success of the surgical
treatment can be predictable
but is strictly related to careful
case selection and operative
skill. Common ECR
classifications have some
ambiguity between their
distinctive categories, and
further improvement is
required to enhance their use
in future research and clinical
practice.
From the Liverpool University Dental
Hospital, Liverpool, United Kingdom
Address requests for reprints to Prof Fadi
Jarad, Liverpool University Dental
Hospital, Pembroke Place, Liverpool, UK.
E-mail address: fjarad@liverpool.ac.uk
0099-2399
Copyright © 2020 The Authors. Published
by Elsevier Inc. on behalf of American
Association of Endodontists. This is an
open access article under the CC BY
license (http://creativecommons.org/
licenses/by/4.0/).
https://doi.org/10.1016/
j.joen.2020.03.006
778 Jebril et al.
The Surgical Management of
External Cervical Resorption: A
Retrospective Observational
Study of Treatment Outcomes
and Classifications
ABSTRACT
Introduction: The aims of this study were to assess the survival and clinical success of
patients with teeth with external cervical resorption (ECR) who underwent surgical repair, to
assess the reliability of using 2 different classification systems for ECR (Heithersay
2-dimensional classification and Patel 3-dimensional classification), and to identify if a
3-dimensional classification is a viable alternative. Methods: A retrospective study was
performed in a teaching dental hospital in England. The inclusion criteria were limited to
patients who underwent surgical management of ECR between 2015 and 2018. Both
periapical radiographs and cone-beam computed tomographic scans of 13 patients were
assessed by 2 independent dental practitioners using the Heithersay and Patel classifications.
The same radiographic assessment of those records was then repeated 3 weeks later by 1
operator. These data were tested using the Cohen kappa analysis to determine inter- and
intraobserver agreement. Results: A total of 14 teeth affected with ECR were identified in 13
patients (6 women and 7 men) with a mean age of 41 years. The mean follow-up was 20
months. At follow-up, survival was noted in all cases; however, clinical success describing
endodontic success, comprehensive restorative integrity, and arrest of the resorptive process
was only met in 11 cases. Although helpful in describing the lesions, both classification
systems displayed considerable limitations in predicting treatment outcome. A measure of
Cohen kappa regarding interobserver reliability found the Heithersay classification to provide a
moderate level of agreement (0.69), whereas the Patel classification provided a weak level of
agreement (0.40). Conclusions: ECR is a complex, aggressive, and uncommon form of
external resorption. The long-term success of the treatment is predictable but strictly related
to careful case selection and operative skill. In reference to ECR classifications, ambiguity still
exists between their distinctive categories, leading to moderate and weak levels of interob-
server agreement. Further improvement is required to enhance their use in future
research. (J Endod 2020;46:778–785.)
KEY WORDS
Classifications; cone-beam computed tomography; endodontics; external cervical
resorption; trauma
Root resorption is the loss of dental hard tissue as a result of osteoclastic action1–3. In the permanent
dentition, root resorption has been associated with a variety of causes, including trauma, impacted teeth,
cystic lesions, and endocrine disturbances such as hyper/hypoparathyroidism and hyper/
hypophosphatemia4–7. The clinical presentation of root resorption is very varied, and significant progress
has been made at classifying these lesions based on site, type of resorptive process, and suspected
etiology8. One of the least understood types of resorption is external cervical resorption (ECR), a unique
pattern of external resorption that affects the periodontal ligament, cementum, and dentin most
commonly found at or below the cervical margin9.
JOE  Volume 46, Number 6, June 2020
 ECR has been described previously in TABLE 1 - Heithersay’s Classification of External Cervical Resorption (Invasive Cervical Resorption)21
the literature as invasive cervical, asymmetric
internal, progressive intradental, peripheral Class I A small invasive resorptive lesion near the cervical area with shallow penetration
cervical, and cervical external resorption2,10. into dentin
Class II A well-defined invasive resorptive lesion that has penetrated close to the coronal
This variation in nomenclature, along with the
pulp chamber but shows little or no extension into the radicular dentin
multifactorial nature of resorption, has resulted
Class III A deeper invasion of dentin by resorbing tissue, not only involving the coronal
in a scattered research picture. A recently dentin but also extending into the coronal third of the root
published position statement by the European Class IV A large, invasive resorptive process that has extended beyond the coronal third
Society of Endodontics (ESE) has gone some of the root
way to provide clarity and establish a baseline
for further research into this condition11.
The ESE position statement highlights
2-dimensional classification system is being radiographic records of all patients who
the uncertainty regarding the exact cause of
challenged by a new 3-dimensional underwent surgical repair of ECR over a 3-year
ECR. Building on recent literature reviews,
classification system proposed by Patel et al18 period. As per HRA guidelines, ethical approval
orthodontics, trauma, bleaching, and
(Table 2). was not required for this study; however,
iatrogenic damage are described as prominent
Patel et al18 described the aims of this approval for the evaluation of the service was
predisposing factors6,11. In the past few years,
classification as a means of ensuring accurate granted by the clinical effectiveness team at a
greater focus has been placed on
diagnosis, a tool for objective outcome UK hospital.
histopathologic analysis with hope that this
assessment, an aid in decision making when The data were obtained by reviewing a
might shed light on a distinct cause and to offer
formulating a treatment plan, and as a hospital surgical log at a National Health
innovative methods for its management12.
communication aid between clinicians. The Service teaching dental hospital. All patients
In current practice, difficulties exist in the
advantage of using CBCT imaging is that it who underwent surgical management of ECR
early identification of ECR because the location
allows for treatment outcomes and prognostic between 2015 and 2018 regardless of their
of the resorption makes it easy to miss in a
factors to be assessed in relation to the follow-up period were included in this study.
visual examination2. This means that although
3-dimensional nature of ECR18. Although Data collection was undertaken by a
highly dependent on the extent of the lesion,
these classification systems are a useful tool, single observer who reviewed the clinical
ECR is typically identified as an incidental
the severity and location of the resorption records. A data collection sheet was
finding and can be easily misdiagnosed as a
pattern as well as relevant patient factors constructed with a focus on preoperative
carious cavity8.
should remain the fundamental principles for patient symptoms, history of previous dental
Plain film radiographs are also
deciding on the treatment modality9. treatment/trauma, and a comprehensive
inadequate diagnostic tools for ECR because
The aim of this study was to assess the clinical and radiographic examination. Various
of the masking effect caused by the relative
survival and clinical success of teeth clinical factors were also examined
radiodensity of the remaining tooth structure
diagnosed with ECR who underwent surgical retrospectively to identify demographics and
and overlying alveolar bone. The often-
management to better inform clinicians on the clinical characteristics, and preoperative
unpredictable shape of the resorptive pattern
prognosis associated with surgery as a radiographic records were reviewed to assess
can also contribute to a delay in identifying the
treatment option. The secondary aim was to the complexity and classification of the lesions.
lesion until significant resorption has already
evaluate the use of the Heithersay and Patel Surgical and endodontic procedures
occurred13,14. Recently, cone-beam
2-dimensional and 3-dimensional classification were undertaken by several postgraduate
computed tomographic (CBCT) imaging has
systems and review their role in providing the endodontic students. All the cases were
been used extensively to provide a more
clinician with salient information on treatment treated according to a similar protocol that
accurate representation of these lesions15,16;
modality and treatment outcome. This study included operating under high magnification,
however, its use needs to be carefully
also reviewed the use of both classification raising a full mucoperiosteal flap with
evaluated, and clinicians should also aim to
systems as an effective and accurate intrasulcular incision and papillae elevation,
maintain the lowest radiation dose for patient
communication tool between clinicians. and completely removing resorptive tissues
exposures17.
with predominantly mechanical debridement.
After a diagnosis of ECR is made, the
Undermined enamel was removed and the
options for treatment can be extensive.
METHODS defect restored with an appropriate restorative
Classification of these lesions can aid in
material before repositioning of the flap. If a
providing an insight into the prognosis of A retrospective observational study was
pulpal exposure were noted during the
treatment options and therefore better inform conducted to review the clinical notes and
the decision making of patients and
clinicians18. The conventional method for the
TABLE 2 - Patel’s 3-dimensional Classification of External Cervical Resorption18
classification of ECR is the Heithersay
classification. A classification system (Table 1)
Circumferential Proximity to the
based on the body of work by Heithersay who
Height spread root canal
used the term invasive cervical resorption in his
studies5,9,19. Heithersay’s proposed 1: At the cementoenamel junction level or A: 90 d: lesion confined
coronal to the bone crest (supracrestal) to the dentin
classification uses plain film radiographs in
2: Extends into the coronal third of the root and B: .90 to 180 p: probable pulpal
categorizing the 2-dimensional infiltration of
apical to the bone crest (subcrestal) involvement
resorption along the root (class I–class IV). 3: Extends into the midthird of the root C: .180 to 270
However, because of the increased use 4: Extends into the apical third of the root D: .270
of CBCT imaging in dentistry, Heithersay’s

JOE  Volume 46, Number 6, June 2020 Surgical Management of External Cervical Resorption 779
TABLE 3 - Results: The Cohen Kappa Inter- and Intraobserver Agreement Coefficients
Interobserver agreement
Category kappa (unweighted)
Heithersay classification
CBCT (whole)
Apical CBCT
Circumferential CBCT
Invasion CBCT
CBCT, cone-beam computed tomography.
Interpretation: value of kappa 5 0–0.20, no agreement; 0.21–0.39, minimal agreement; 0.40–0.59, moderate agreement;
0.80–0.90, strong agreement; and above 0.90, almost perfect agreement.
debridement stage, a standard root canal
treatment access would be performed and a
suitable gutta-percha point used to maintain
the space before completion of surgical repair;
this prevented occlusion of the canal space by
the restorative material.
As per local protocol, all patients were
recalled for routine postoperative review after
surgical management of ECR. Supplementary
analysis of postoperative plain film radiographs
was undertaken to review the structural
integrity of restoration and any progression of
the resorptive lesion and to note any
endodontic/periodontal pathology.
Using the clinical notes and
postoperative radiographs, 3 tooth-specific
outcomes criteria were created for this study:
1. Failure: loss of tooth because of operative
failure or patient symptoms
2. Survival: tooth in situ at the time of follow-up
review with no patient-reported symptoms
3. Clinical success: the tooth meets survival
criteria and presents with sound structural
integrity of the restoration, lacks evidence
of further progression of the disease
process, and demonstrates endodontic
success as per ESE guidelines20
A review of preoperative plain film
radiographs allowed the assignment of the
Heithersay classification21, and CBCT imaging
allowed the use of the Patel 3-dimensional
TABLE 4 - Agreed External Cervical Resorption Classification Undertaken between 2 Different Observers in Both
3-dimensional (3D) and Heithersay Classification
Agreed Heithersay classification
Agreed 3D classification
Cases lack representation of Heithersay class IV and lesions of depths 1 and 4 in 3D classification.
780 Jebril et al.
brief, sharp shooting pain was the most
common (n 5 2), with others noting recurrent
Intraobserver agreement infections and general discomfort. Two
kappa (unweighted) patients recalled a history of orthodontics, 5 a
0.69 0.53 history of dental trauma, and 1 patient had a
0.40 0.57 history of both orthodontics and dental
0.68 0.70 trauma. All teeth were assessed with either
0.67 0.70 endofrost (ROEKO Endo-Frost, Coltene,
0.60 0.69 Switzerland) or an electric pulp tester before
treatment; 7 teeth had a positive
response, and 7 teeth provided a negative
response. All patients underwent
preoperative plain film radiographic
assessment; 10 patients also underwent
classification18. The images were reviewed by
supplemental CBCT scans to aid in diagnosis
2 observers independently, and the results
and treatment planning.
were used to provide an interobserver reliability
A review of the preoperative
measure. The assessment of intraobserver
radiographs allowed the assignment of a
reliability was completed after a 3-week period.
Heithersay classification and 3-dimensional
After determining the intra- and
classification. The subsequent inter- and
interobserver reliability, any discrepancy in
intraobserver agreement is described in
classifications between the observers was
Table 3, showing a discrepancy in
ratified in a tabled discussion between the
interobserver reliability between the Heithersay
observers to reach a consensus labeled as the
and Patel classifications. Intraobserver
“agreed classification.”
reliability was similar for both classifications.
The data were entered into an Excel
The agreed-on classifications for this cohort
spreadsheet (Excel 16, Office 365; Microsoft,
according to the tabled discussion are
Redmond, WA), and SPSS software (IBM
described in Table 4.
Corp, Armonk, NY) was used for statistical
All teeth underwent surgical
analysis. The intra- and interobserver reliability
intervention, 10 of which required a combined
was calculated using the Cohen kappa
root canal treatment. All patients were
coefficient22.
reviewed postoperatively with a mean review
time of 20 months (range, 8–48 months). A
RESULTS survival rate of 100% was recorded. However,
the success rate was lower at 79%. A sample
Demographic Factors and of preoperative and postoperative imaging can
Preoperative Characteristics be seen in Figures 1 and 2.
The records of 13 patients were identified with
ECR, 7 of whom were male and 6 were female.
The age range of these patients was 22–66 DISCUSSION
years, with an average of 41 years. There were
To achieve predictable lasting success, careful
14 ECR-affected teeth in total with 12 identified case selection in the management of ECR is of
in the maxilla, 10 of which were central incisors paramount importance21. The pathogenesis
and 1 was a lateral incisor. The majority of and etiology of ECR remain poorly
patients were asymptomatic on presentation understood23. The cohort of this study
(n 5 7), but for patients who noted symptoms, provides a unique insight into ECR and its
management. The results noted in this study
show a distinct homogeneity in ECR
presentation with a relatively similar
male:female ratio.
Classification Number of cases A review of the etiology noted a
Class I 1 considerable number provided a history of
Class II 8 trauma (46%, n 5 6) and orthodontics (23%,
Class III 5 n 5 3), which is consistent with previous
2Ap 1 research2,5,8, and although the remainder of
2Bd 2 the cohort 38% (n 5 5) did not recall a history
2Bp 3 of any predisposing factors, this could be
3Ad 1
attributed to the unreliability of patient
3Ap 1
recollection when collecting this information
3Bp 1
3Cp 1 from patients in the clinic24. The distribution of
ECR, with the majority of cases associated
with maxillary incisors (79%, n 5 11), also
JOE  Volume 46, Number 6, June 2020
FIGURE 1 – Preoperative and postoperative plain film radiographs of selected cases. Case numbers are synonymous with the cases in Figure 2.

JOE  Volume 46, Number 6, June 2020 Surgical Management of External Cervical Resorption 781
FIGURE 2 – CBCT image displaying axial, sagittal, and coronal views of corresponding resorptive lesions preoperatively in selected cases. Case numbers are synonymous with those in
Figure 1.

supports the suggestion of trauma being a the presence of ECR on 2 lower molars with no causes. In this study, the majority of patients
major etiologic factor, with maxillary incisors notable etiology, a finding that casts doubt on were asymptomatic at consultation, and half of
being the most common teeth to undergo trauma being the only factor and supports the the teeth were still responsive to pulpal
dental trauma25,26. However, it is worth noting need for further research to explore other sensibility assessment. These findings appear

782 Jebril et al. JOE  Volume 46, Number 6, June 2020

consistent with the description of a slow
disease process that, for the most part,
has limited pulpal involvement in its early
stages12.
Because of the 3-dimensional nature
of the resorption pattern, any operative
procedure presents a considerable
challenge23. Ensuring complete cessation of
the resorption process while maintaining the
function of the tooth requires careful
evaluation of the lesion before operative
intervention21. Various options for managing
the resorption lesion have been proposed,
but the focus of this study was on patients
who underwent surgical access, direct
curettage, and restoration of the resorption
defect. The operative techniques used in this
study followed established protocols for the
surgical management of ECR with the only
notable deviation being the omission of
trichloroacetic acid in chemical
debridement27. In the United Kingdom,
trichloroacetic acid is challenging to source
and carries considerable risk if inadvertently
applied to the oral mucosa; therefore, its use
was discouraged following a risk/benefit
assessment28. Upon comprehensive removal
of the granulomatous tissue, the cavity is
prepared and restored using an appropriate
restorative material such as glass ionomer
cement or composite23. In this study, resin-
modified glass ionomer cement was the
most common restorative material because it
provided adequate esthetics in an
environment where moisture control can be
challenging29. When ECR had penetrated
the root canal system, a root canal
treatment was initiated at the time of
surgery. This too was done using
established protocols in which a
conventional root canal access is performed,
the root canal is identified, and an
appropriately sized gutta-percha point is
used to maintain patency before restoration
of the resorption defect. Root canal
treatment was required in 71% (n 5 10) of
cases.
Classification systems are used
extensively in dentistry30–32. Their use is
predominantly research focused because they
allow uniformity of descriptors and play a
significant role in providing data on treatment
outcomes. The most prominent example of
this in ECR is the Heithersay classification21.
This classification was initially developed for
research purposes but went on to provide
prognostic data showing that treatment of
Heithersay class I, II, and III lesions carries a
considerable chance of a favorable outcome,
whereas class IV lesions are best monitored or
extracted. On review of preoperative plain film
radiographs, the Heithersay classification for
JOE  Volume 46, Number 6, June 2020
teeth treated in this study had a distribution of
7% class I, 57% class II, and 36% class III, a
distribution consistent with Heithersay’s
findings.
The cumulative survival rate for all teeth
involved in this study was 100% at recall,
which occurred on average 20 months
postoperatively. A postoperative assessment
of clinical success was undertaken as per the
tooth-specific criteria set in the method. With
these strict criteria, success was noted in 79%
of teeth.
The failures were attributed to the
continued progression of resorption defect
and the suboptimal restoration integrity of 7%.
The failures included 2 central incisors and 1
mandibular molar. The classifications for these
teeth were 3Cp (American Dental Association
Universal Numbering System) for tooth 8, 3Bp
for tooth 9, and 2Bp for tooth 31. These
lesions were classified as Heithersay class III,
III, and II, respectively. Both central incisors
had extensive lesions extending into the middle
third of the root with a circumferential spread of
150 –200 (Figure 2 [image 10]). The
resorption pattern had significantly
undermined the structural integrity of these
teeth; therefore, the aim of surgical
management was to limit the rate of the
disease process before extraction and
restorative replacement. On review 19 months
postoperatively, these teeth were still
functional and asymptomatic but displayed
signs of continued resorption (Figure 1
[image 10]).
The majority of patients in this study
underwent a preoperative CBCT scan for
treatment planning. Three patients did not
undergo CBCT scans as clinical
examination, and plain film radiographs
provided sufficient information to guide the
treatment; further irradiation would have
been of limited value. The latest guidance
notes that CBCT scans are recommended
for the diagnosis and management of all
ECR cases33.
Using the Patel 3-dimensional
classification, the distribution in this study was
wide-ranging, from 2Ad to 3Cp. 2Bp was the
most common classification with 21% (n 5 3)
followed by 2Bd with 14% (n 5 2).
The use of plain film radiographs in the
assessment of a 3-dimensional resorptive
lesion has clear limitations that can be
overcome by the development of CBCT
technology. By providing a comprehensive
3-dimensional representation of the lesion,
CBCT imaging can improve the diagnosis and
management of ECR.
The secondary aim was to evaluate the
use of the Heithersay and Patel 2-dimensional
and 3-dimensional classification systems and
Surgical Management of External Cervical Resorption
review their role in providing the clinician with
salient information on treatment modality and
treatment outcome. This study also reviewed
the use of both classification systems as an
effective and accurate communication tool
between clinicians.
In order to evaluate these classification
systems, it was important to establish how
they are used in a clinical environment. One of
the key indicators of the quality of a
classification system is its reliability. By
proposing a new classification, clinicians have
a responsibility to identify any areas that might
lead to classification error and therefore be
detrimental to the usefulness of the system as
a whole. Reliability estimates are useful tools to
assess the quality of a classification system.
These parameters are used to evaluate the
test-retest reliability (a measure of the reliability
of a classification system used by the same
individual at different times) and the interrater
reliability (a measure of consistency between
different observers classifying the same cases).
In this study, Cohen kappa was used because
it is an established and recognized measure of
inter- and intraobserver agreement22.
When comparing the interobserver
agreement of the Heithersay and Patel
classifications, Heithersay’s was superior
(moderate agreement compared with weak
agreement). It is worth pointing out that if
Patel’s classification is broken down into its
constituent parts, then both systems
demonstrated moderate levels of agreement.
When analyzing the intraobserver agreement,
both classifications were found to offer weak
agreement.
It is clear that both systems have their
limitations; Heithersay’s was mostly caused by
the use of a 2-dimensional image, whereas
Patel’s classification was restricted by its
tripartite nature and the ambiguity in some of
its descriptors.
At a tabled discussion to identify the
cause of disagreement when using Patel’s
classification, 3 areas of conflict were noted.
The first is the change in language between
subclassification 1 and 2. When identifying the
height of the lesion, subclassification 1
describes a lesion “at the CEJ
[cementoenamel junction] or supracrestal,”
whereas subclassification 2 specifies a lesion
“into coronal third of root and subcrestal.” This
causes ambiguity in lesions that present in the
coronal third of the root but remain
supracrestal because of the presence of
pathologic bone loss. A lesion that involves the
coronal third of the root but is supracrestal is
shown in Figure 2 (image 7).
The second is the circumferential
spread description that uses degrees to
assess the spread; although this is adequate
783
for the majority of cases, it can be challenging
in U-shaped lesions and when the lesion has a
nonuniform shape, often leading to over- or
underestimation. This is best shown in image 8
in Figure 2 where an estimation of
circumferential spread is ambiguous.
The third is regarding the use of the
word “probable” when assessing proximity to
the root canal. This introduces an element of
subjectivity in an otherwise robust and
objective classification system. By using
“probable,” it made classifications of lesions
such as that seen in image 5 in Figure 2
difficult. This study notes caution with using the
pulpal component of this classification. Three
teeth with “p” (probable pulp involvement) did
not require subsequent root canal treatment,
and 2 teeth with “d” (lesion confined to dentin)
did. This highlights the importance of clinical
examination, preoperative sensibility
examination, and intraoperative assessment of
pulpal exposure as the principal method for
dictating treatment.
A final point of consideration in this
classification relates to the omission of the
lesion’s orientation. This issue is best
highlighted using an example of 2 teeth of
identical classification (ie, 2Bd). Tooth number
1 can present with a buccally isolated lesion
with a reasonable chance for visualizing the
defect and successful management, whereas
tooth number 2 can present with a 2Bd lesion
that has considerable crossover
interproximally from buccal to palatal and
therefore provides a comprehensively different
challenge altogether.
CONCLUSION
In conclusion, although this study presents
with a small sample size and a limited review
period, it does lend support to the viability of
surgical treatment for Heithersay class I–III
lesions and Patel 2Ad–3Cp, having shown
survival in 100% of cases and clinical success
in 79% of cases with an average review period
of 20 months. ECR remains a poorly
understood form of root resorption and
remains challenging to diagnose and treat. The
increased use of CBCT imaging and operating
microscopes has made it possible to be more
confident of a successful outcome, but careful
case selection remains essential when
managing ECR.
This study also highlights some of the
limitations of using 2-dimensional and
3-dimensional classification systems.
Regarding the introduction of the Patel
classification, the authors find that this
classification can play a significant role in
shaping future research of ECR and be of
substantial clinical relevance when compared
with Heithersay’s classification. Although still in
its infancy, Patel’s classification does show
promise as a more reliable classification
system that will aid in establishing a uniform
research base, but it would benefit from slight
refinement in light of our findings before its
universal adoption.
CREDIT AUTHORSHIP
CONTRIBUTION STATEMENT
Ahmed Jebril: Conceptualization,
Methodology, Data curation, Writing- original
draft. Sanaa Aljamani: Validation, Writing-
review & editing. Fadi Jarad:
Conceptualization, Supervision, Writing-
review & editing.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.

REFERENCES
1. Bolhari B, Meraji N, Nosrat A. Extensive idiopathic external root resorption in first maxillary molar:
a case report. Iran Endod J 2013;8:72–4.
2. Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: a review. J Endod
2009;35:616–25.

3. Patel S, Ford TP. Is the resorption external or internal? Dent Update 2007;34:218–29.
4. Andreasen JO. External root resorption: its implication in dental traumatology, paedodontics,
periodontics, orthodontics and endodontics. Int Endod J 1985;18:109–18.
5. Heithersay GS. Invasive cervical resorption following trauma. Aust Endod J 1999;25:79–85.

6. Heithersay GS, Dahlstrom SW, Marin PD. Incidence of invasive cervical resorption in bleached
root-filled teeth. Aust Dent J 1994;39:82–7.
7. Bansal P, Nikhil V, Kapur S. Multiple idiopathic external apical root resorption: a rare case report.
J Conserv Dent 2015;18:70.

8. Darcey J, Qualtrough A. Resorption: part 1. Pathology, classification and aetiology. Br Dent J

2013;214:439.

9. Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption.
Quintessence Int 1999;30:27–37.
10. Gold SI, Hasselgren G. Peripheral inflammatory root resorption: A review of the literature with
case reports. J Clin Periodontol 1992;19:523–34.

11. European Society of Endodontology, Patel S, Lambrechts P, et al. European Society of

Endodontology position statement: external cervical resorption. Int Endod J 2018;51:1323–6.

12. Mavridou AM, Hauben E, Wevers M, et al. Understanding external cervical resorption in vital
teeth. J Endod 2016;42:1737–51.

784 Jebril et al. JOE  Volume 46, Number 6, June 2020

 13. Bernardes RA, de Paulo RS, Pereira LO, et al. Comparative study of cone beam computed
tomography and intraoral periapical radiographs in diagnosis of lingual-simulated external root
resorptions. Dent Traumatol 2012;28:268–72.

14. Kamburog
lu K, Kursxun Sx, Yu € x B. Observer ability to detect ex vivo simulated internal
€ksel S, Oztas
or external cervical root resorption. J Endod 2011;37:168–75.

15. de Souza DV, Schirru E, Mannocci F, et al. External cervical resorption: a comparison of the
diagnostic efficacy using 2 different cone-beam computed tomographic units and periapical
radiographs. J Endod 2017;43:121–5.

16. Patel S, Dawood A. The use of cone beam computed tomography in the management of external
cervical resorption lesions. Int Endod J 2007;40:730–7.
17. Pauwels R, Beinsberger J, Collaert B, et al. Effective dose range for dental cone beam computed
tomography scanners. Eur J Radiol 2012;81:267–71.

18. Patel S, Foschi F, Mannocci F, Patel K. External cervical resorption: a three-dimensional

classification. Int Endod J 2018;51:206–14.

19. Heithersay GS. Invasive cervical resorption: an analysis of potential predisposing factors.
Quintessence Int 1999;30:83–95.
20. European Society of Endodontology. Quality guidelines for endodontic treatment: consensus
report of the European Society of Endodontology. Int Endod J 2006;39:921–30.

21. Heithersay GS. Invasive cervical resorption. Endod Topics 2004;7:73–92.

22. Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med
2005;37:360–3.

23. Patel S, Foschi F, Condon R, et al. External cervical resorption: part 2–management. Int Endod J
2018;51:1224–38.

24. Kaste LM, Gift HC, Bhat M, Swango PA. Prevalence of incisor trauma in persons 6 to 50 years of
age: United States, 1988–1991. J Dent Res 1996;75:696–705.
25. Zerman N, Cavalleri G. Traumatic injuries to permanent incisors. Dent Traumatol 1993;9:61–4.

26. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature.
Aust Dent J 2000;45:2–9.

27. Heithersay GS. Management of tooth resorption. Aust Dent J 2007;52:S105–21.

28. Naranjo Ortega UR, Mejía LR. Use of a lower concentration of trichloroacetic acid to manage
invasive cervical resorption: a case report. Endod Pract Today 2019;13:71–5.

29. Yiu CK, Tay FR, King NM, et al. Interaction of resin-modified glass-ionomer cements with moist
dentine. J Dent 2004;32:521–30.
30. Feliciano KM, de França Caldas A Jr. A systematic review of the diagnostic classifications of
traumatic dental injuries. Dent Traumatol 2006;22:71–6.

31. Fisher J, Glick M, FDI World Dental Federation Science Committee. A new model for caries
classification and management: the FDI World Dental Federation caries matrix. J Am Dent Assoc
2012;143:546–51.

32. Papapanou PN, Sanz M, Buduneli N, et al. Periodontitis: consensus report of workgroup 2 of the
2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and
Conditions. J Periodontol 2018;89:S173–82.

33. Patel S, Durack C, Abella F, et al. European Society of Endodontology position statement: the use
of CBCT in endodontics. Int Endod J 2014;47:502–4.

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