A Clinical Approach Strategy For The Diagnosis Treatment and Evaluation of External

Received: 5 December 2020
| Accepted: 6 January 2022
DOI: 10.1111/iej.13680
ORIGINAL ARTICLE
A clinical approach strategy for the diagnosis, treatment

and evaluation of external cervical resorption
Athina-Maria Mavridou1,2,3 | Eléonore Rubbers1 | Alexander Schryvers1 |

Arno Maes1 | Marcel Linssen2 | Dick S. Barendregt2 | Lars Bergmans1 |
Paul Lambrechts1
1
Department of Oral Health Sciences, Abstract
BIOMAT Research Cluster, KU Leuven
Aim: To propose a clinical approach strategy on the diagnosis, treatment and evalu-
& University Hospitals Leuven, Leuven,
Belgium ation of external cervical tooth resorption (ECR) cases. To investigate and discuss the
2
Private Practice, Proclin Rotterdam, outcome of this approach.
Rotterdam, The Netherlands Methodology: A clinical approach strategy on ECR was developed based on a retro-
3
Department of Oral Health Sciences,
spective observation study of 542 teeth. Forty-seven teeth were excluded due to lack
Section of Endodontology, Dental
School, Ghent University, Ghent, of clinical/radiographical information, and 182 were immediately extracted. This
Belgium approach had three steps: diagnosis, treatment planning and evaluation. During di-
agnosis, the medical, dental history and clinical/radiographical characteristics were
Correspondence
Athina-Maria Mavridou, Department evaluated. Depending on the resorption extent, ECR cases were categorized into four
of Oral Health Sciences, Section of classes according to Heithersay's classification. During treatment planning, a treat-
Endodontology, Dental School, Ghent
University, C. Heymanslaan 10/P8,
ment decision flowchart was prepared based on four main decisive criteria: probing
9000 Ghent, Belgium. feasibility, pain, location and extent of resorption (class), and existence of bone-like
Email: athimavridou@gmail.com tissue. Three treatment options were applied: (a) extraction, (b) monitoring or (c)
conservative treatment by external, internal or combination of internal-external
treatments. During evaluation, assessment of ECR progression, tooth survival and
other factors like aesthetics and periodontal attachment were performed. Descriptive
statistical analysis of the outcome for up to 10 years (for the overall clinical ap-
proach and for each individual treatment decision), was carried out with OriginLabs
OriginPro 9 and Microsoft Excel 365.
Results: A three-step strategy was developed on how to deal with ECR cases.
Indicative examples of each treatment decision were presented and discussed.
The overall survival rate of this strategy was 84.6% (3 years), 70.3% (5 years), 42.7%
(8 years) and 28.6% (10 years). Higher survival rate was observed for external treat-
ment decision than for internal. The success of each treatment decision depended
on the extent of the resorption (class). The success of a treatment decision should be
based on the long-term outcome, as a different evolution can be observed with time.
Conclusions: A clinical approach strategy was introduced on ECR pathosis. This
strategy was not solely based on ECR class, as other important decisive criteria
were considered. This step-wise approach, has a 70.3% survival rate with a mean of
© 2022 International Endodontic Journal. Published by John Wiley & Sons Ltd.
Int Endod J. 2022;55:347–373. wileyonlinelibrary.com/journal/iej | 347

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348 CLINICAL APPROACH STRATEGY FOR ECR
5 years. This work will hopefully provide an incentive for a broader collaboration, to
potentially establish a universally accepted ECR treatment strategy.
KEYWORDS
diagnosis, external cervical resorption, outcome, treatment
I N T RO DU CT ION Indicative examples can be found in recently published

articles (Asgary & Nosrat, 2016; Salzano & Tirone, 2015;
External cervical resorption (ECR) is a dynamic process by Shemesh et al., 2017) where teeth with ECR categorized
which the tooth structure is damaged due to activation of as class IV were successfully treated by using an internal
clastic cells and removal of mineralized tissue (Mavridou, approach.
Bergmans, et al., 2017). It is widely known that ECR can In addition, other research groups (Estevez et al., 2010;
evolve with time and thus can be categorized into four Gonzales & Rodekirchen, 2007; Hiremath et al., 2007;
classes, depending on its extent (Heithersay, 1999a). Schwartz et al., 2010; Smidt et al., 2007; Vinothkumar
Furthermore, it has been proposed by Heithersay (1999b, et al., 2011) proposed an interdisciplinary treatment ap-
2007) that based on the extent of ECR (class), a different proach that takes into consideration the complexity of
treatment should be applied. In particular, he proposed that ECR pattern. However, most of the published work is
in classes I and II (less invasive form), the resorption tissue based on a limited number of teeth and is focused only on
should be removed with the application of 90% of trichloro- the treatment itself and not on the treatment planning. It
acetic acid (TCA) and curettage followed by restoration of should be pointed out that in private practice most of the
the resorption cavity. In class II, partial pulpectomy could failed treatments are due to an incomplete assessment/
also be performed in order to gain access to the resorption diagnosis, which subsequently led to inappropriate plan-
channels. Alternative therapy could be periodontal flap re- ning. This clearly indicates that there is a need to establish
flection, followed by the application of TCA and curettage guidelines that define/discuss how to perform diagnosis,
of the defect, combined with endodontic treatment and which factors to consider, and then how to plan the most
direct restoration. In class IV (more invasive form), there effective treatment option.
are two options: or to leave it untreated and monitor the This paper proposes a clinical approach strategy for
progression of ECR or to remove the tooth. the diagnosis, treatment and evaluation of ECR cases,
However, research reports have shown that this eval- based on extensive research performed at KU Leuven in
uation, which is based only on the 2D extent of ECR, collaboration with Proclin Rotterdam. This clinical ap-
has many limitations (Patel, Foschi, et al., 2016; Patel, proach strategy is in accordance with the recent position
Mannocci, et al., 2016). This is because it does not take statement of ESE (2018) since it considers the 3D charac-
into consideration the reparative stage, as well as the true teristics of ECR and supports the need of CBCT for the di-
3D extent of the resorption. A recent report by Patel et al. agnosis, treatment planning and evaluation of ECR cases.
(2018) suggests a 3D classification based on CBCT mea- However, it also includes additional decisive criteria such
surements. Also, in this work, four classes are proposed, as the as the existence of pain, the formation of bone-like
but the main difference is that in this updated classifi- tissue and probing feasibility, which to the authors' point
cation the ECR lesion height, the circumferential spread of view, are important factors when selecting a treatment
around the root canal and the proximity to the root canal decision. Indicative clinical examples are also presented
are also included. and discussed, in order to illustrate the rationale behind
From the above research works, it is suggested that the each treatment decision. In addition, the applicability of
clinical approach should be solely dependent on the 2D the proposed clinical approach strategy is evaluated by
or 3D extent of the resorption (class). However, despite performing survival, success and failure analysis of the
the fact that the extent is a major criterion for the clini- long-term (10 years) outcome. The lack of research on
cal approach of ECR, there are also other important fac- long-term ECR outcome is clearly mentioned in the ESE
tors to consider. For example, the presence of bone-like position statement (2018).
(mineralized) tissue (Gunst et al., 2013; Luso & Luder,
2012; Mavridou, Hauben, et al., 2017; Mavridou, Hauben,
et al., 2016; Mavridou, Pyka, et al., 2016), pain sensation METHODOLOGY
and probing feasibility (is the resorption cavity externally
accessible during probing?), should be taken into account This clinical approach strategy is in accordance with
during the diagnosis and before treatment planning. STROBE statement and is a retrospective observational
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MAVRIDOU et al. 349
study of 542 ECR cases, which were referred to KULeuven Cone-beam CT: CBCT analysis was performed to deter-
(Clinical Trial Centre registration number S54693) from mine and evaluate the position, 3D extent, depth in relation
January 2009 until December 2019 and were examined, to the root canal and the Pericanalar Resorption Resistant
treated and evaluated by the same three experienced en- Sheet (PRRS) (if it existed), the ingrowth of reparative
dodontists/periodontists. From the initial 542 cases, 47 bone-like tissue in the resorption cavity, the portal(s) of
were not included because there was a lack of clinical entry and external and PDL interconnections (portal(s) of
and/or radiographical information, and 182 were imme- exit) (Mavridou, Hauben, et al., 2017; Mavridou, Hauben,
diately extracted (based on decision strategy criteria e.g. et al., 2016). The need to use CBCT technique for a correct
pain). The characteristics of the study group are given in diagnosis and evaluation is confirmed by the position state-
Table 1. This approach consists of three steps, namely, di- ments of ESE on ECR (2018) and on CBCT (2014, 2019)
agnosis, treatment planning and evaluation. and the position statement of the AAE/AAOMR (2015).
To draw safe conclusions, both intraoral clinical and radio-
graphical observations were combined.
Diagnosis Each ECR case was categorized into four classes based
on the resorption extent, as first proposed by Heithersay
The diagnosis was based on the following criteria: (1999a), as the 3D classification (Patel et al., 2018) did not
Medical and dental history: In this work, we used exist at that time. A post analysis based on the 3D clas-
the recently proposed checklist by Mavridou, Bergmans, sification was feasible, but due to the complexity of this
et al. (2017) to identify potential predisposing factors. In classification and heterogeneity of the study group, too
particular, we screened for the age, gender, tooth type many sub-categories occurred (32 in total). This made
and all clinical conditions and iatrogenic procedures that the planning of an easy-to-follow treatment strategy ex-
can cause cementum & PDL damage, PDL compression, tremely difficult, at least at this stage. However, it should
hypoxia and chronic irritation (Mavridou et al., 2019). be noted that for this clinical approach strategy, apart
Indicative examples are orthodontics, trauma, intracoro- from the class we also considered 3D characteristics (as
nal bleaching, periodontal surgery, parafunctional habits, described previously) that are not included in the existing
poor oral health etc. 3D classification.
Clinical examination: Clinical examination consisted
of intraoral and radiographical evaluation.
Intraoral examination: During intraoral examination, Treatment planning
we identified whether the patient had tooth pain, tooth
discoloration/ pink spot, swelling, gingival discomfort The treatment of ECR can vary due to the complexity of
and/or sinus track. Afterwards, we investigated if the re- this phenomenon. In this work, four main criteria (two
sorption cavity was visible at the cervical part and if the clinical and two radiographical) were evaluated before
tooth was in infraocclusion due to bone-like tissue in- making a treatment decision: (a) existence of pain, (b)
growth. Probing was then performed to assess the size probing feasibility of the resorption cavity (c) 2D class and
(small ≤ 0.5 mm, large ≥ 5 mm), location and morphology 3D characteristics (as defined previously) and (d) exist-
(e.g. single or multiple, with granulation or bone tissue) ence of bone-like tissue.
portal(s) of entry. Sensibility tests were used to evaluate Based on these factors, three treatment decisions are
pulp reaction. Finally, percussion/palpation/mobility proposed. The first one is to remove the tooth. Another
tests were performed to identify any abnormalities (e.g. option is to monitor the tooth, with eventual treatment
metallic sound with percussion and decreased mobility of later or extraction when the tooth becomes symptomatic.
the tooth indicate ankylosis). A third option is to treat the resorption either with an in-
Conventional periapical radiography: The teeth were ternal, external approach or a combination. This can be
divided into four main classes, based on the 2D classifi- performed by lesion access, debridement and restoration.
cation of Heithersay (1999a), as a 3D classification (Patel
et al., 2018) was not available at that time. Apart from the
extend (class) of the resorption, we evaluated whether: (a) Evaluation
the resorption area was radiolucent or radiopaque, (b) if
there were irregular or sharp margins in cervical/proximal The evaluation was done on a yearly basis after the ini-
region and (c) if a white line was visible at the margins of tial diagnosis of ECR. In cases were a periodontal flap was
root canal. A second X-ray was also taken at a different raised, follow-up was done after the first and third week,
angle to detect if the resorption defect is shifting, in order as well as after the third month to evaluate periodontal
to differentiate from internal resorption. healing and then on a yearly basis. Also, when patients
|
TABLE 1 Overview of all ECR cases considered in this study and their characteristics per treatment approach (censored data are
included)
Treatment Internal External Combination Monitoring
Characteristics Nr % Nr % Nr % Nr %
Overall
Teeth 47 8.67 92 16.97 67 12.36 154 28.41
Patient 45 9.57 87 18.51 65 13.83 110 23.40
Gender
Female 23 48.94 32 34.78 25 37.31 75 48.70
Male 24 51.06 60 65.22 42 62.69 79 51.30
Age
10–19 10 21.28 21 22.83 5 7.46 22 14.29
20–29 14 29.79 16 17.39 13 19.40 27 17.53
30–39 10 21.28 16 17.39 13 19.40 44 28.57
40–49 6 12.77 17 18.48 13 19.40 27 17.53
50–59 3 6.38 13 14.13 15 22.39 17 11.04
≥60 4 8.51 10 10.87 8 11.94 18 11.69
Tooth type
Maxillary incisors 14 29.79 43 46.74 28 41.79 35 22.73
Maxillary canines 3 6.38 12 13.04 12 17.91 13 8.44
Maxillary premolars 3 6.38 3 3.26 2 2.99 18 11.69
Maxillary molars 7 14.89 6 6.52 6 8.96 19 12.34
Mandibular incisors 2 4.26 7 7.61 0 0.00 9 5.84
Mandibular canines 0 0.00 5 5.43 8 11.94 11 7.14
Mandibular premolars 2 4.26 8 8.70 4 5.97 22 14.29
Mandibular molars 16 34.04 8 8.70 7 10.45 40 25.97
Pain/Symptoms
No 35 74.47 82 89.13 44 65.67 136 88.31
Yes 11 23.40 10 10.87 21 31.34 3 1.95
No info 1 2.13 0 0.00 2 2.99 15 9.74
Class
Class 1 5 10.64 15 16.30 5 7.46 28 18.18
Class 2 9 19.15 52 56.52 11 16.42 26 16.88
Class 3 21 44.68 18 19.57 37 55.22 40 25.97
Class 4 11 23.40 4 4.35 12 17.91 45 29.22
No info 1 2.13 3 3.26 2 2.99 15 9.74
Portal(s) of entry
Single 33 70.21 6 6.52 52 77.61 98 63.64
Single Vestibular 7 14.89 39 42.39 15 22.39 12 7.79
Single Lingual/Palatal 8 17.02 29 31.52 20 29.85 42 27.27
Single Intraproximal 18 38.30 18 19.57 17 25.37 44 28.57
Multiple 14 29.79 5 5.43 15 22.39 41 26.62
No info 0 0.00 1 1.09 0 0.00 15 9.74
Size of the portal of entry
Small (≤0.5 mm) 30 63.83 9 9.78 9 13.43 90 58.44
Large (≥0.5 mm) 16 34.04 82 89.13 56 83.58 49 31.82
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MAVRIDOU et al. 351
TABLE 1 (Continued)
Treatment Internal External Combination Monitoring
Characteristics Nr % Nr % Nr % Nr %
No info 1 2.13 1 1.09 2 2.99 15 9.74

Bone ingrowth
Yes 24 51.06 13 14.13 14 20.90 94 61.04
No 22 46.81 78 84.78 51 76.12 45 29.22
No info 1 2.13 1 1.09 2 2.99 12 7.79
Probing feasibility
Yes 26 55.32 85 92.39 59 88.06 38 24.68
No 20 42.55 6 6.52 6 8.96 101 65.58
No info 1 2.13 1 1.09 2 2.99 15 9.74
had poor oral hygiene, then a more frequent recall was performed the diagnosis and treatment and then dis-
planned every 3 months. cussed between them, to achieve the best possible objec-
During this evaluation, clinical examination was tivity. Subsequent statistical analysis was performed with
performed to examine the periodontal and endodontic OriginLabs OriginPro 9 and Microsoft Excel 365, to assess
tissues. Careful probing was crucial to assess any possi- the success, failure and survival rates for up to 10 years.
ble changes at the periodontal attachment. A small FOV In this way, both the outcome of the overall clinical ap-
CBCT was considered (ESE position statement 2014) proach strategy and of each individual treatment decision
mainly in monitoring cases, to evaluate if there were any were assessed. When performing the outcome analysis
radiographical changes at the ECR lesion. To overlap the on a yearly basis, teeth with equal or higher follow-up
initial with follow-up CBCT data and to accurately visual- period were included, along with all the teeth that had
ize any possible changes, Amira 3D software (version 6.4) failed earlier, in accordance with the fundamental work of
was used (Thermo Fisher Scientific-FEI). Heithersey (1999b).
Depending on the findings of the evaluation process,
additional follow-up actions were decided. Such actions
included: instructions for oral hygiene, polishing of the RESULTS
restoration, evaluation of occlusion and articulation com-
bined with adjustment if needed, revision of the treat- In the results, clinical examples are presented to illustrate
ment, new follow-up appointment or tooth removal. the importance of each step in the proposed clinical ap-
Based on the evaluation protocol described previously, proach strategy.
three main outcome criteria were created for this study,
taking also into consideration relevant published work
(Heithersay, 1999b; Irinakis, 2018; Jebril et al., 2020). Diagnostic step
These criteria are:
Medical and dental history: During the medical and
1. Failure: loss of the tooth due to pain, resorption dental history, the potential predisposing factor(s) in-
progression, vertical fracture, restorative failure or volved in the initiation of ECR were identified. Patients
periodontal problems. that had undergone or undergo orthodontic treatment,
2. Clinical success: no pain or other clinical signs, satis- or have parafunctional habits, have a risk for ECR. In
factory aesthetic results, resorption is stable and/or addition, specific combinations of potential predispos-
remodelling occurs, healing or absence of a periapi- ing factors were observed to have a synergetic effect, as
cal lesion and remaining periodontal pocket with no one destroys the PDL and the other causes a hypoxic
bleeding. environment. Indicative suspicious combinations are
3. Survival: the tooth is present during the follow-up, extraction of a neighbouring tooth in combination with
without any pain. occlusal overloading or orthodontics with poor oral
health. The medical and dental history is important to
All clinical and radiographical data from the consid- identify these factors and their combinations so as to
ered ECR cases were independently reviewed by the minimize their effect which may lead to possible further
same three experienced endodontists/periodontists who progression of ECR.
|
The age of the patient is an important factor to consider have to remove bone to gain access to the resorption. A
before treatment decision. ECR was found in patients at monitoring approach (Figure 4)/or internal approach
any age, but the factors responsible in any case can be dif- (Figure 5) was selected instead.
ferent. Furthermore, despite the fact a long-term progno- In the clinical cases where soft (epithelium and granu-
sis of teeth with ECR is yet feasible, depending on the age lation) tissue grew through the portal(s) of entry, probing
of the patient, different approaches can be adopted. For was feasible (Figure 3b). An invasion of dental plaque bac-
example, in young patients suffering from ECR and whilst teria was observed to cause inflammation and pain, and
having an orthodontic treatment indication, an alterna- thus a monitoring approach was not adopted. Instead, an
tive treatment could be autotransplantation. external approach was selected.
Pain. The existence of pain or any discomfort (any type
of pain such as pulpitis/apical periodontitis-like symp-
Intraoral clinical examination toms or/and periodontal pain that could cause incon-
venience to the patient) was also a crucial factor for our
Tooth type. This is extremely important in the case of ca- decision-making. If the involved tooth or the periodontal
nines because when extraction treatment is selected, it can tissues caused pain, then monitoring was unsuitable.
alter the occlusion and the articulation, as explained in the Aesthetics. Aesthetics were important when ECR appeared
work of Rinchuse et al., 2007. Therefore, we either treated in front teeth, as it could create a pink spot (Figure 6). In such
or we avoided/postponed extraction of canines. The pos- clinical cases, we did not consider monitoring, but instead, we
sibility to use an implant was considered. However, due either treated or extracted this tooth. When performing treat-
to the high occlusal pressure risk of biomechanical failure ment, the granulation tissue (that was responsible for the pink
(Sadan et al., 2004), other treatments such as autotrans- spot) was removed and cavity was restored. When treating was
plantation and/or orthodontics, were preferred. not possible, we extracted the tooth and proceeded with a re-
Location of the portal(s) of entry (initiation points of storative treatment (e.g. autologous bridge).
resorption). The portal(s) of entry can be located in the Status of the pulp. When apical periodontitis (Figure
buccal/palatal/lingual/interproximal area or in a combi- 7) or irreversible pulpitis was diagnosed, then a root canal
nation of them (Figure 1). This location plays an import- treatment was performed. In all other cases, a root canal
ant role since it defines the external accessibility of the treatment was avoided to maintain the vital pulp tis-
resorption and whether a crown lengthening procedure sue, which helps to maintain the PRRS layer and hinders
is possible. Interproximal areas were more difficult to ac- the progression of ECR (Mavridou, Hauben, et al., 2017;
cess, whereas they were more prone to aesthetic compli- Mavridou, Hauben, et al., 2016). When pulp perforation oc-
cations (papilla recession) after treatment. Access at the curred during the treatment of ECR, a direct pulp capping
buccal side was technically easier than at the palatal side. procedure was performed (Figure 8) or a partial pulpotomy.
Size of the portal(s) of entry. A small portal of entry Periodontal health (pockets, oral health). It is important
(≤0.5 mm) combined with a large resorption cavity (Figure to ensure that our patients were able to access the treated
2) was technically easier to restore by using an internal ap- area, in order to maintain a good periodontal health. In the
proach. It should be pointed out that during the internal monitoring approach, we provided our patients with addi-
treatment process we firmly sealed the portal(s) of entry, tional and detailed instructions on how to maintain good
to prevent communication with external blood vessels, oral health and avoid plaque accumulation in the ECR area.
which can lead to resorption progression. Occlusion and articulation. When necessary, we eval-
Probing feasibility of the portal(s) of entry. In our pro- uated and corrected the occlusion and articulation of the
tocol, probing feasibility was determined solely on the patient. Any premature contacts, occlusal imbalance and
existence of bone ingrowth. This was also confirmed by parafunctional habits that could cause overloading of the
CBCT analysis. Other factors that could also have a strong affected teeth were assessed (e.g. by digital T-scan occlusal
influence are the resorption position (e.g. interproximal analysis) (Montgomery et al., 2011) (Figure 9), to reduce
position, depth within the biological width) and the exis- hypoxia at the periodontal ligament level and to prevent
tence of pain during probing. However, this does not nec- tooth fracture.
essarily mean that the probing is not technically feasible.
In addition, in all of the cases that we have investigated,
we never had to do anaesthesia. Radiographic examination
In the case that bone ingrowth occurred through the
portal(s) of entry (Figure 3a), probing was not technically Conventional 2D radiographic imaging provided a
possible. An external approach was not chosen because first indication of the extent of resorption (2D class).
this would have been a more invasive treatment as would However, CBCT (3D Accuitomo 170, Morita) was used
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MAVRIDOU et al. 353
(a)
(b)
(c)
(d)
FIGURE 1 The portal of entry (=initiation point) located in (a) the vestibular, (b) lingual, (c) interproximal area or (d) in a combination
of those
to visualize better the location, size and relationship of ligament (portal(s) of entry and portal(s) of exit) was
the resorption with the pulp (Figure 10). A better ob- possible (Figure 10). Based on the size and location
servation of the resorption channels through the tooth of the resorption channels (Figure 10), we decided
structure and the interconnections with the periodontal whether it was technically possible to remove them or
|
Portal
of entry
(a) (b) (c)
Resorption
PRRS
Resorption
Resorption
(d) (e)
F I G U R E 2 ECR case on tooth 36 exhibiting a small portal of entry and a large resorption cavity. (a) 2D radiographic image. CBCT
imaging: (b) 3D rendering, (c) coronal, (d) sagittal and (e) axial view. PRRS: Pericanalar Resorption Resistant Sheet
not. In addition, with the use of CBCT we investigated Treatment planning step
the existence and extent of the Pericanalar Resorption
Resistant Sheet (Figures 2e, 5c, 5g, 6c, 10e) and possi- The treatment choices are categorized into 3 major groups:
ble perforations into the pulp (Figure 10e). Depending Tooth removal. When tooth restoration was hopeless
on these factors different decisions were made (e.g. vital and there was pain, extraction was selected. A resto-
pulp therapy and root canal treatment). In molars, re- ration was considered hopeless when: (a) the extent was
sorption areas were found between pulp horns above categorized as class III or IV, (b) the portal of entry was
the pulp roof, below the pulp floor (Figure 2d) or along large and (c) reparative bone formation was not visible.
the root canal (Figures 5e, 10). This was important in Other options that were considered, was to first make a
order to gain access to these areas: (1) a root canal treat- restorative plan (e.g. implant, autologous bridge) and then
ment (Figure 5) or (2) a vital pulp therapy (Figure 8) proceed with the extraction (Figure S1). In cases of multi-
was decided. Finally, the ingrowth of mineralized tissue rooted teeth, a root amputation of the resorbed root was
(bone) through the portal of entry was seen (Figure 4a). considered. Another possibility was to perform a mini-
As mentioned before, in our protocol this factor deter- mal invasive tooth extraction followed by an endodontic/
mined the probing feasibility of the resorption. restorative treatment and replantation, as in the work of
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MAVRIDOU et al. 355
F I G U R E 3 Comparison between
two ECR class IV cases (a) with bone (a)
ingrowth and no probing feasibility of the
resorption cavity and (b) without bone
ingrowth and with probing feasibility
Bone
ingrowth
(b)
No bone
ingrowth
Krug et al., 2019. However, in our treatment approach, we secondary bacterial invasion into the resorption area that
did not select this option. could possibly reactivate inflammation and resorption
Monitoring. When bone ingrowth was visible through progression.
the portal(s) of entry (probing was not feasible) and there Restorative treatment of the resorption area. We chose
were no clinical symptoms, monitoring the tooth (after between the following options:
the first 6 months and then on a yearly basis) was per- Internal approach. In this protocol, after giving anaes-
formed (Figure 4). If clinical (e.g. pain, probing) or ra- thesia the tooth was isolated with rubberdam. Then based
diographical (e.g. extent of resorption, remodelling of on the CBCT 3D image, a modified accesses cavity was cre-
the bone tissue) changes occurred in the 2D periapical ated with a diamond bur, in order to facilitate the removal
X-ray, then we either continued to monitor with a CBCT of the resorption defect (Figures 5, 8). For the removal of the
(Figure 4a–c) or we performed a treatment (Figure 4d) or resorption tissue, long neck (LN) burs or diamond-coated
extraction. Sometimes, it was difficult to evaluate changes spherical ultrasonic tips were used (Acteon). Throughout
in the radiographical appearance of the resorption area. the internal approach, a high magnification microscope
This is because these changes might not always be due to was used. Afterwards, the resorption cavity was cleaned
progression of the resorption but also due to bone remod- by using 2.5% of sodium hypochlorite. A root canal treat-
elling. Indicative examples are given in Figure 4b, where a ment was not always selected (Figure 8). If technically
part of the resorption area changes from radiopaque (rep- possible, the pulp was kept vital and a direct capping or
resenting bone-like tissue) to radiolucent (representing a partial pulpotomy was performed (Figure 8) by apply-
soft tissue) and in Figure 4c, where a part of the resorption ing MTA (Angelus). Above this layer, glass ionomer liner
area changes from radiolucent to radiopaque. Emphasis (Vitrebond, 3M ESPE) was applied. Recent publications
was given in eliminating any potential predisposing fac- have shown that teeth with a root canal treatment and
tors (e.g. occlusion overloading, parafunctional habits). ECR have a more aggressive form of ECR. Furthermore, it
Also, good oral health instructions were given to prevent is believed that a vital pulp plays a positive protective role
|
Initial CBCT After 2 years

(a)
Bone
No radiographical
ingrowth
changes

(b) Radiopaque Radiolucent
Radiographical
changes
(c)
Radiolucent Radiopaque
No
Resorpon Resorpon
channels channels Radiographical
changes
Initial CBCT After 1 ½ year Portal of
Treatment
(d) Radiographical changes entry
Radiopaque Radiolucent
F I G U R E 4 Four clinical cases where monitoring approach was applied due to bone ingrowth. After their re-evaluation it was found
that (case a) no clinical and radiographical changes occurred, (case b) no clinical symptoms but slight radiographic changes as some areas
became more radiolucent, (case c) no clinical symptoms but radiographical changes occurred as some areas became more radiopaque and
(case d) clinical (the patient reported pain and the resorption cavity was possible to probe) and radiographical changes (some areas were
more radiolucent and a larger portal of entry) occurred. Due to probing feasibility, pain and progression of resorption a combination of
internal - external approach was applied. Alignment of the CBCT data was done with the Amira 3D Software
in the progression of ECR (Mavridou, Hauben, et al., 2017; instruments (Dentsply, Maillefer), ultrasonic activation of
Mavridou, Hauben, et al., 2016). However, from a technical 2.5% of NaOCl and final irrigation of EDTA and NaOCl.
point of view, a root canal treatment was often inevitable Obturation was done by using gutta-percha and AH-plus
so as to gain access and treat invasive forms of ECR (e.g. sealer with a combination of warm lateral condensation.
resorption channels) (Figure 5e,d). Chemo-mechanical Emphasis was given during the internal approach on the
preparation was performed by using Gates Glidden, hand firm closing (restoring) of the portal(s) of entry (Figure
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MAVRIDOU et al. 357
Portal of entry (c)
PRRS Resorption
channel
Bone
Portal ingrowth
(a) (b) of entry (d) (e)
(f) (g) (h)
PRRS
Portal
of entry
Resorption
(i) (j)
Portal
of entry
F I G U R E 5 ECR case on tooth 16, where the portal of entry was too small and external probing was not feasible due to bone ingrowth.
(a) 2D radiographic image. CBCT imaging: (b) coronal (c) axial view at the portal of entry, (d) sagittal view of the palatal root, (e) axial view
showing resorption channel in the palatal root. (f) Bleeding coming from the resorption tissue. (g) PRRS layer. (h) Portal of entry. (i) Sealing
of the portal of entry with MTA. (j) Radiographical image after internal approach and root canal treatment
5) and external interconnections, which were identified so as to have the highest accessibility (Figure 12). For an
during CBCT investigation. This was done by placing optimal adaptation of the soft and hard tissues to the res-
MTA (Angelus) into the portal of entry and then above toration, an additional crown lengthening procedure was
that a layer of glass ionomer liner (Vitrebond, 3M ESPE). performed to limit the violation of the biological width
Finally, the access cavity was restored by a composite ma- (Figures 11f, 12e). From the apical border of the resorp-
terial (Clearfil DC Core Plus, Kuraray). tion, 2–2.5 mm of bones were removed by using crown
External approach. During this approach, the resorp- extension surgical tips (Satelec, Acteon) and a Piezotome
tion cavity was completely treated externally by raising a (Implant center, Acteon). In the cases where gingival over-
full-thickness periodontal flap (Figure 11). In particular, growth occurred (Figures 14, 15) and there were no aes-
after anaesthesia, full thickness intrasulcular incisions thetic considerations, then gingivectomy was performed.
were performed. Prior to removal of the resorption tissue within the cav-
In order to get access to the ECR defect, the incision ity, we placed a rubberdam (as shown in Figure 13), so as to
was long enough and, if necessary releasing incisions avoid contamination of the dentinal tubules and the pulp.
were carefully applied at the least aesthetically compro- In the majority of cases we used rubberdam, except in a very
mising locations. The intradental papilla was left intact, few cases were the extent of the resorption was too large.
by elevating and moving it at the opposite direction of the After isolation, the resorption tissue was removed with
ECR defect. In the case of a palatal flap, we secured the a sharp excavator in one go. The edges of the cavity were
raised flap with a suture (4–0, Ethibond Excel, Ethicon), shaped by using diamond-coated Sonicsys tips (Kavo). The
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(a)
Pink spot (b)
PRRS
(c)
(d) (e)
F I G U R E 6 ECR case on tooth 11. (a) Pink spot. (b, c) Extent of the resorption as identified by CBCT. (d) Clinical and (e) radiographic
appearance of the same tooth after external treatment by a flap and a restoration with composite. The tooth was kept vital
(a) (b) (c) (d) (e) (f)
F I G U R E 7 ECR case on tooth 44 with apical periodontitis. CBCT images of (a, b, c) initial condition of this tooth. (d, e, f) Yearly
evaluation confirming the complete healing of this tooth after a combination of external–internal approach
resorption cavity was thoroughly cleaned by using physio- but there was a thin pericanalar layer present, we applied
logical saline (Sodium Chloride 0.9%) sterile solution and first a light cured glass ionomer cement liner (Vitrebond,
sterile sponge pellets soaked with 2.5% of sodium hypo- 3M) and above that a dual-cure composite (Clearfil DC Core
chlorite. In addition, LN burs and ultrasonic tips (Satelec, Plus, Kuraray) or glass ionomer (Fuji IX, GC).
Acteon) were used to remove any granulation tissue that The soft tissues were trimmed and adapted to osseous
was still present in the resorption channels and under the surfaces to provide a shallower pocket, and then single
edges of the cavity. If perforation with the pulp was visible, interrupted sutures (6-0, Perma Sharp, Hu-Friedy) were
then pulp capping was performed as explained previously. placed. The patients were instructed to rinse with 0.12%
The cavity was then restored by using composite (Filtek of chlorhexidine gluconate twice a day, for 1 week. After
Supreme XTE, 3M ESPE) and/or glass ionomer cement 1 week, the sutures were removed and the patient was ad-
(Fuji IX, GC). When there was no perforation in the pulp vised to brush the treated area with a soft toothbrush to
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MAVRIDOU et al. 359
(a) (b) (c) (d)

PRRS
Portal
Bone ingrowth
of entry
F I G U R E 8 ECR case on tooth 16 showing internal approach (a) initial 2D radiographic image. (b) coronal and (c) axial CBCT view
and (d) 2D radiographic image after direct overcapping procedure with MTA and restoration with composite (internal approach without
endodontic treatment)
F I G U R E 9 Example of a T-Scan showing occlusal force distribution. High bite force percentages (indicated by red arrows) are seen
at both canine and right molar areas. These percentages are calculated automatically by dividing the bite force in that area with the total
measured bite force
avoid further trauma. Instructions on how to maintain a 3. Location and extent of resorption (class). Based on
good oral hygiene were given to the patient to help him these findings, we decided if the treatment was techni-
achieve a good healing of the periodontal tissues. The cally possible or if the tooth was hopeless.
patient was then scheduled for control after 2 weeks, 4. Existence of bone-like tissue. If bone ingrowth was vis-
1 month, 3 months, 6 months and then on a yearly basis. ible through the portal(s) of entry then a less invasive
Combination internal-external. This interdisciplinary ap- approach (e.g. monitoring) was applied.
proach was used when there were very large resorption cav-
ities and excavation was not possible externally. It was also Furthermore, we always considered four general crite-
used for clinical cases where the resorption channels were ria to achieve a satisfactory tooth restorability. These cri-
visible (Figure 15). Furthermore, this combined approach teria were:
was used when the restoration placed during the internal
approach had to be finalized externally, to ensure that the 1. the restorative treatment should not damage the neigh-
portal of entry was completely sealed. Finally, in apical peri- bouring teeth,
odontitis/pulpitis cases, root canal treatment was inevitable. 2. the restored tooth should not be prone to fracturing,
Based on the authors' experience, four main decisive 3. the aesthetic result should be satisfactory and
criteria need to be considered. These are: 4. the periodontal attachment would be adequate.
1. Existence of pain. In this case, a monitoring approach

was not applied, and treatment or extraction was Evaluation
performed.
2. Probing feasibility. When probing was not feasible then In the monitoring cases, during evaluation, a re-
an internal approach or a monitoring approach were examination of decisive criteria (pain, probing feasi-
considered. bility, 3D extent of resorption and repair) was carried
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Portals of entry/exit
Portals of entry/exit
(c) (d)
(a) (b)
(e) (f)
PRRS
Pulp
perforation
Resorption
Resorption channels channels
F I G U R E 1 0 (a) 2D radiographic imaging of tooth 43 showing ECR. CBCT imaging: (b) 3D rendering of the vestibular side (c) sagittal
view (d) 3D rendering in the lingual side (e) axial view of (c), (f) coronal view
out. If changes occurred (e.g. patient had pain) (Figure 3. Are there any premature contacts or is there a maloc-
4d), then either treatment or extraction of the tooth was clusion that could cause a fracture to these teeth?
performed. When clinical findings were unchanged 4. Are there any aesthetic considerations?
(pain, probing) but radiographical changes were visible
(CBCT image), a careful judgement on the ‘why’ these Depending on the findings, additional follow-up ac-
changes occurred was made (Figure 4). This is because tions were planned. Such actions included: instructions
small changes on the CBCT can be due to either resorp- for oral hygiene, occlusion and articulation evaluation
tion progression (Figure 4d) or normal bone remodel- and adjustment, revision of the treatment, new follow-up
ling (Figure 4b,c). Bone remodelling can occur when appointment or extraction planning. By eliminating any
the bone-like tissue inside the tooth becomes resorbed potential aetiological factors (for example poor oral health
and then replaced by newly formed bone. In such cases, or malocclusion), the active resorption process could be
the tooth was not treated/extracted but it was further shifted towards a more stabilizing or reparative process
monitored. (Figure 4c).
In the treated cases during the evaluation step, we Based on these points, a clinical approach strategy for
asked the following questions: ECR diagnosis, treatment planning, performance and
evaluation was prepared. This approach is presented as a
1. Are there any clinical or radiographical findings sug- simplified flowchart, which points out the key factors and
gesting that resorption has progressed? decisive criteria that were considered/addressed in every
2. What is the status of the periodontal attachment? Are step (Figure 16).
there any remaining pockets that need aftercare or is To evaluate the success of this proposed clini-
there any new loss of the periodontal attachment? cal approach, the survival, success and failure rates
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MAVRIDOU et al. 361
(a) (b) (c) (d) (e)
PRRS
(f) (g) (h)
(i) (j) (k)
F I G U R E 1 1 (a) 2D radiographic (b) clinical and (c, d, e) CBCT view of a case of severe ECR on tooth 13. External treatment by a
periodontal flap: (f) flap elevation and crown lengthening, (g) pulp capping with MTA and restoration with glass ionomer, (h) suturing of
the flap, (i) healing 1 week later and (j) clinical and (k) radiographic recall after 1 year
were assessed according to the fundamental work of the survival and success rates decrease afterwards. One
Heithersay (1999b), Figure 17. For this work 542, teeth should also bear in mind that the survival and success
with ECR were considered. However, from these cases, rates are strongly depended on post-treatment time.
47 were not included because there was a lack of clini- Indeed, analysis of the outcome per year showed a higher
cal and/or radiographical information, and 182 were im- survival and success during the first 3 years, Figure 18.
mediately extracted (based on decision strategy criteria However, it dropped considerably with increasing time.
e.g. pain etc.). An overview of the considered teeth per To the authors' point of view, the reason for this decrease
year is given in Table 2. The survival rate for this pro- is actually twofold. On one hand, the failure rate in-
posed clinical approach strategy was 84.6% with a mean creased due to either vertical root fracture or due to ECR
of 3 years, 70.3% with a mean of 5 years, 42.7% with a progression. In particular, out of the 60 teeth that were
mean of 8 years and 28.6% with a mean of 10 years. The extracted after 10 years, 33 (7 out of 8 in internal treat-
success rate was 49.8% with a mean of 3 years, 41.3% with ment, 3 out of 7 in external treatment, 13 out of 21 in
a mean of 5 years, 17.5% with a mean of 8 years and 9.5% combination treatment and 9 out of 24 teeth in monitor-
with a mean of 10 years. This indicates that the proposed ing cases) were due to vertical fracture and 25 (1 out of 8
clinical approach is promising for the first 5 years, but in internal treatment, 3 out of 7 in external treatment, 5
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(a) (b) (c) (d)
(e)
(f) (g)
F I G U R E 1 2 (a) 2D radiographic image (b, c, d) CBCT view of a severe ECR case on tooth 21. (e) External treatment by a periodontal
flap, crown lengthening and restoration with glass ionomer. Sutures are used to secure the flap. (f) Clinical and (g) radiographic recall after
1 year
out of 21 in combination treatment and 14 out of 24 teeth slightly misleading as (a) the long-term outcome includes
in monitoring cases) because of ECR progression. The a much smaller number of teeth compared to the initial
remaining cases (1 out of 7 in external treatment, 3 out study group (in this work 274 were considered during
of 21 in combination treatment and 1 out of 24 teeth in the first year, and 84 after 10 years), (b) all earlier fail-
monitoring cases) were extracted for restorative reasons. ure cases are included in the long-term outcome (in ac-
On the other hand, such statistical calculations can be cordance with the work of Heithersay (1999b)) and (c) a
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MAVRIDOU et al. 363
(a) (b) (c) (d)
(e) (f)
(g) (h)
F I G U R E 1 3 (a) 2D radiographic and (b, c) CBCT view of a case of ECR on tooth 22, (d) rubberdam placement after flap elevation, (e)
restoration with composite, (f) suturing of the flap, (g) clinical situation after 1 week and (h) radiographic recall after 1 year
considerable number of patients did not return for a con- To get a better understanding of the survival, success and
trol check (typically patients that have no complication failure for each treatment decision, descriptive statistical
and/or pain, decide to skip any further post-operative analysis was performed and is presented in Figure 18. It can
control until a complication occurs). To draw safe conclu- be seen that the initial survival rate is relatively high for all
sions on the late outcome, a sufficient number of teeth types of treatment. However, after the first 3 years, a clear
should be recalled and well documented. For this reason, separation can be seen, as the survival rate for ‘internal’ and
the authors will continue to follow-up these ECR cases. ‘combination internal-external’ drops. Interestingly, after
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(a) (b) (c) (d)
Gingival overgrow
(e) (f) (g)
(h) (i)
(j) (k)
F I G U R E 1 4 (a) Clinical image and (b, c, d) CBCT view of a case of ECR on tooth 11 with gingival overgrowth into the resorption cavity.
External approach by gingivectomy: (e) shaping the edges of the cavity (black arrows) with ultrasonic tips, (f) gingivectomy, (g) resorption
cavity after gingivectomy and after cleaning with a sponge pellet soaked in sodium hypochlorite, (h) pulp pseudo-capping, (i) applying a
base layer with glass ionomer, (j) matrix placement, (k) restoration with composite and (l) radiographic recall after 1 year
7 years, a separation between ‘monitoring’ and ‘external similar trend as the descriptive statistical analysis (Figure
treated cases’ can be observed, as the survival rate of the S2a). However, some differences could be observed. With
monitored cases decreases clearly. This is an indication that Kaplan–Meier analysis the combination of external-
‘monitoring approach’ can ‘buy some time’ (especially in internal approach appears to have the lowest survival rate,
cases of canine teeth or cases with patients were the restor- whereas all the other treatments had a considerably higher
ative plan had to be postponed), but there is always a time survival probability. This is because in Kaplan–Meier statis-
limit. Teeth where an indication for external treatment was tics censored data are included.
chosen seemed to have the best prognosis. Further analy- One of the most widely identified factors for the suc-
sis of the outcome with Kaplan–Meier statistics revealed a cess of a treatment (Heithersay, 1999; Irinakis, 2018) is
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MAVRIDOU et al. 365
(a) (b) (c) (d)

Root canal
Resorption
channel
Resorption
channel
(e) (f) (g)
(h) (i) (j)

Resorption
channel
F I G U R E 1 5 (a) Clinical image, (b) 2D radiographical and (c, d) CBCT view of a case of ECR on tooth 11. Combination of external-
internal approach: (e) gingivectomy and removal of the resorption cavity, (f) resorption tissue attached on enamel removed in one piece,
(g) applying a base layer with glass ionomer and matrix placement, (h) restoration with composite, (i) internal treatment with open cavity
(bleeding indicates existence of resorption channel) and (j) radiographic recall after 1 year
the extend (class) of the resorption. A representation II and III, ‘external’ approach had the highest survival
of the survival rate per class confirms that class I has a rate, especially in the long term (Figure 20b,c). During
higher survival rate (Figure 19). However, using such the first 4–5 years, no clear separation can be seen be-
a simple representation can be misleading, as different tween ‘external’ and ‘monitoring’ treatment decision. A
treatment methods are used per class (e.g. more inva- clear differentiation is evident only after 5 years (Figure
sive internal approach is rarely used in classes I and 20b,c). For class IV, ‘internal’ approach had the high-
II). For this reason, the survival rate of each treatment est long-term survival rate, followed by ‘monitoring’
is plotted per class in Figure 20. In class I, ‘monitoring’ (Figure 20d). For this class, the survival rate of ‘exter-
approach has a higher survival rate, than ‘external’ and nal’ treatment decision is the lowest (Figure 20d), con-
‘combination internal-external’ (Figure 20a). In this trary to class II and III cases (Figure 20b,c) where it is
proposed clinical strategy, ‘internal’ approach was not the highest. Analysis by Kaplan–Meier method showed
performed for class I cases, as it was considered to be similar trends but higher survival rates for each treat-
more invasive. In addition, monitoring was mainly con- ment approach (Figure S2c,d,e). Only noticeable differ-
sidered for cases where ECR defect was substituted by ence is that for class III, internal approach has a much
bone and probing was not possible. The same tendency higher survival probability rate. This is because after
was also found with Kaplan–Meier analysis, but also 5 years, the ratio between actual and censored data
in this case the survival probability was higher due to changes considerably (more censored data than the ac-
consideration of censored data (Figure S2b). For classes tual ones).
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Treatment approach strategy: flowchart

Diagnosis: Medical & dental history, intra-oral clinical, and 2D & 3D radiographic examinaon
Class I Class II Class III Class IV
Main deciding criteria are the resorption probing feasibility, pain sensation, the location and extent
(class) of resorption and the existence of bonelike tissue.
Monitoring Restorave treatment Tooth removal

When resorption probing is When the location and extent When there is pain and probing of
not feasible and/or bonelike of resorption allows for the resorption is feasible
tissue is detected at the portal restoration When criteria for a satisfactory tooth
of entry When criteria for a satisfactory restorability are not fulfilled:
When there is no pain and/or tooth restorability are fulfilled a) restorative treatment damages the
the extraction/ restoration neighbouring teeth
could be postponed b) restored tooth is prone to fracturing
Treatment c) high chance that the aesthetic result
would not be satisfactory
d) periodontal attachment would be
Elimination of potential
Treatment inadequate
predisposing factor(s) if possible
Other options: autologe bridge,
Internal approach if bonelike
Elimination of potential decoronation, root amputation
tissue is detected at the portal of
predisposing factor(s) if entry and/or no probing of the
possible defect is feasible
Supra-gingival scaling and Internal approach
checking of occlusion
Instructions for maintaining Removal of resorption
a good oral health to prevent External approach defect from the inside and
plaque at the resorption area sealing of the portal of
Crown lengthening procedure if entry
restoration violates the biological Performing preferably vital
width pulp therapy
Pulp capping (if needed)
Endodontic treatment
(combination external-internal)
to treat resorption channels, or if
there is pulpitis and/or apical
periodontitis symptoms
Evalua on of the treatment

Clinical criteria: pain, probing
Radiographical criteria: extent and location of resorption and existence of bonelike tissue (small FOV CBCT)
Follow-up ac ons
When only clinical changes occur (e.g. pain, probing): extraction or new treatment and re-evaluation
When only radiographical changes occur: continuing monitoring
When both clinical and radiographical changes occur: extraction or new treatment and re-evaluation
Instructions for good oral hygiene, evaluation and adjustment (if needed) of the occlusion & articulation
Follow-up at least on a yearly basis
FIGURE 16 Simplified schematic of the proposed clinical approach strategy for treating ECR cases
DI S C US S I O N updated 3D classification (2018) takes under considera-

tion the lesion height, the circumferential spread around
In the proposed clinical approach, the first step includes the root canal and the proximity to the root canal (exist-
the diagnostic procedure of ECR. In this step, in every ence of PRRS). Besides this information, the clinician
class, a difference in the radiographic characteristics is should also consider other 3D findings before final diag-
observed. Heithersay's classification (1999a) is based nosis and treatment decision. These factors include the
on the 2D extent of the resorption, whereas Patel et al. location of the resorption (buccal, lingual, interproximal
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MAVRIDOU et al. 367
(a) (b)
3 years 5 years
(c) (d)
8 years 10 years
F I G U R E 1 7 Overview of all teeth considered per year. Survival, success and failure rates for (a) 3, (b) 5, (c) 8, and (d) 10 years for the
overall clinical approach strategy and for each treatment decision
or a combination), the location and size of the portal(s) the interface between resorption and repair is not always
of entry, the repair by bone-like tissue formation and the visible (Mavridou, Hauben, et al., 2016).
pulpal status (e.g. vitality status, obliteration, periapical In this proposed clinical approach, a flowchart is pre-
radiolucency). Furthermore, in class III, the extent be- sented based on the class and other clinical and radio-
tween the pulp horns and pulp floor (in molar teeth) and graphical deciding criteria (Figure 16).
the existence of interconnections with the PDL should be In class I cases as defined in this protocol, an internal
evaluated. In class IV, an additional characteristic is the approach is not applicable due to the position and extent
existence of resorption channels through the tooth struc- of resorption at the external tooth surface. In classes II–
ture and their extent is critical. IV, we have three options: (a) tooth removal, (b) moni-
It should be noted that, in this research work the toring or (c) treatment. Based on four decisive criteria,
decision-making is not based solely on the resorption the most appropriate treatment should be chosen. The
class. This is mainly because both existing classifications main decisive criteria are the resorption probing fea-
do not take into account the reparative nature of some sibility, pain sensation, the location and extent (class)
ECR lesions, which is believed to play a vital role in the of resorption and the repair by bone-like tissue. When
pattern of ECR. Other factors that should be taken into resorption probing is not feasible, reparative bone-like
account before treatment planning are age of the patient, tissue is detected at the portal(s) of entry and there is no
potential aetiological factor(s), tooth type, pain sensation, pain then a monitoring approach should be considered.
probing feasibility, location and size of the portal(s) of If there is pain then the clinician should either extract
entry, aesthetics, pulp and periodontal status and occlu- the tooth or treat (by internal, external approach or a
sion and articulation. Amongst these factors, the authors' combination). An extraction is indicated when the cri-
identified the following four as the main decisive criteria: teria for the tooth restorability are not fulfilled. In the
pain, probing feasibility, location and extent (class) of re- cases that restoration is possible and there is no bone-
sorption and repair by bone-like tissue. like tissue ingrowth, then a restorative treatment can be
Another limitation of a treatment decision which considered. In this case, the location and extent (class)
is only based on the 3D extent of the resorption is that of resorption and the location and size of the portal of
CBCT analysis can underestimate the ‘true’ extent of the entry are important factors in order to decide the treat-
resorption (Mavridou, Pyka, et al., 2016). This is because ment approach (external, internal).
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TABLE 2 Yearly overview of the actual ECR cases considered for the analysis outcome of this clinical approach strategy
Years
Treatment Initial 1 2 3 4 5 6 7 8 9 10
Internal 46 32 27 20 13 8 4 3 3 2 2
class I: 5 class I: 0 class I: 0 class I: 0 class I: 0 class I: 0 class I: 0 class I: 0 class I: 0 class I: 0 class I: 0
class II: 9 class II: 10 class II: 9 class II: 7 class II: 3 class II: 1 class II: 1 class II: 0 class II: 0 class II: 0 class II: 0
class III: 21 class III: 14 class III: 12 class III: 7 class III: 6 class III: 5 class III: 1 class III: 1 class III: 1 class III: 1 class III: 1
class IV: 11 class IV: 8 class IV: 6 class IV: 6 class IV: 4 class IV: 2 class IV: 2 class IV: 2 class IV: 2 class IV: 1 class IV: 1
External 89 76 61 48 34 28 20 16 10 8 7
Combination 65 52 47 31 27 21 13 10 9 8 7
Monitoring 139 107 99 88 74 64 50 32 22 11 8
Extracted teeth from 7 22 34 38 51 53 55 59 60 60
previous years are class I: 0 class I: 0 class I: 1 class I: 1 class I: 2 class I: 2 class I: 2 class I: 3 class I: 3 class I: 3
included to the class II: 1 class II: 2 class II: 5 class II: 6 class II: 9 class II: 10 class II: 10 class II: 10 class III: 24 class II: 10 class II: 10 class III: 25
following years class III: 2 class III: 11 class III: 14 class III: 16 class III: 22 class III: 23 class III: 24 class IV: 22 class III: 25 class IV: 22
class IV: 4 class IV: 9 class IV: 14 class IV: 15 class IV: 18 class IV: 18 class IV: 19 class IV: 22
Note: In each treatment, the number of teeth per 2D class is described per year (censored data are not included).
CLINICAL APPROACH STRATEGY FOR ECR
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MAVRIDOU et al. 369
F I G U R E 1 8 Evolution of (a)
survival, (b) success and (c) failure
rates per year for the proposed clinical
approach strategy
Another important suggestion of this clinical approach Pyka, et al., 2016) observing that repair can take place by
strategy, when compared to previous treatment proposals, bone apposition. It should be clarified that the monitoring
is that a monitoring approach is considered not only for approach is proposed only if the patient has no pain or irri-
class IV cases but can be applied to all ECR classes. This ap- tation and probing of the resorption is not possible.
proach is based on previous research (Mavridou, Hauben, The probing feasibility is also believed to be crucial. If
et al., 2017; Mavridou, Hauben, et al., 2016; Mavridou, probing of the resorption cavity can be performed, then
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F I G U R E 1 9 Effect of class on
survival rate for the treatment clinical
strategy
(a) (c)
Class I Class III
(b) (d)
Class II Class IV
FIGURE 20 Survival analysis per treatment decision for (a) class I, (b) class II, (c) class III and (d) class IV
there is a risk of secondary invasion of plaque and peri- healing (Plotino et al., 2021), as it allows for restorative
odontal pathogens that can enter into the resorption area treatment without the need for bone resection (surgical
and can lead to inflammation and pain. crown lengthening). However, there is still a lack of ev-
In recent years (Krug et al., 2019; Patel, Foschi, et al., idence for teeth with cervical resorption (Plotino et al.,
2016; Patel, Mannocci, et al., 2016), intentional replan- 2021). In our study we decided (based on our clinical
tation was also considered as an alternative treatment and research experience) not to include this approach,
option for ECR cases. In specific cases and if correctly for the following reasons. First, due to the fact that the
performed, there is a good chance for periodontal PDL is missing at the cervical area and it can also be
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MAVRIDOU et al. 371
locally damaged and/or missing in other areas of the when these teeth interfere with the growth of the patient
root. This can lead to an unsuccessful PDL healing after (teeth become ankylotic). In such cases, extraction should
replantation. Secondly, because an additional root canal be considered for both functional and aesthetic reasons.
treatment is needed. By doing so, the integrity of the Also, survival analysis indicated that a monitoring ap-
tooth structure might be compromised. proach can be followed for up to 5–6 years (Figure 18a),
At the evaluation step, the dentists should consider but for longer periods, the dentist should re-evaluate the
all clinical and radiographical changes. In monitoring progression of the resorption and decide if a treatment
cases, to determine the ‘progression’ of ECR we suggest or a continuation of the monitoring approach is more
a 2D periapical X-ray and clinical control after the first appropriate.
6 months and then follow-up checking on a yearly basis. Survival analysis with Kaplan–Meier method showed
When radiographic and or/ clinical changes occur, then similar trends amongst the selected treatment approaches
a small FOV CBCT should be considered. However, cli- per class, as in the descriptive statistics (Figure S2).
nicians should have in mind the limitations of CBCT. In However, higher survival rates were estimated as the cen-
particular, when comparing follow-up CBCT images of a sored data were included in the calculations. To our point
resorption area, sometimes it is very difficult to visualize of view, we prefer to use graphs without censored data be-
and assess changes. This is because they can be due to ei- cause the study group is more controlled and unbiased.
ther resorption progression or bone remodelling (Figure That is why the results derived from descriptive statistical
4). In the first case, depending on how significance of the analysis appear more critical, but have higher certainty as
resorption progression, a more invasive approach can be only well followed up cases were included. Also, the cred-
used (treatment, extraction). In the second case, further ibility of Kaplan–Meier method strongly depends on the
monitoring of the tooth is preferred. size of the study group (Bollschweiler, 2003) (e.g. much
This treatment approach has an overall survival rate smaller recall of teeth after 8 years).
of about 70.3% with a mean of 5 years. In recent publica- To get an even better insight into this approach strat-
tions (Asgary et al., 2019), survival rates of 100% were re- egy, the authors intend to continue their research on long-
ported. This indeed looks outstanding, but unfortunately, term survival. In particular, we intend to investigate the
these reports considered a limited number of teeth and link between potential prognostic factors (e.g. age, loca-
<3 years of follow-up time. As it can clearly be seen in this tion, size of portal of entry) and individual treatment op-
work (Figures 17 and 18), to draw safe conclusions, long tions (e.g. crown lengthening versus gingivectomy, use of
follow-up times are essential, as the separation becomes rubberdam or not) and the obtained outcome.
more pronounced after the first 5 years. From the applied
treatments, external approach seems to have the highest
survival rate. However, post survival analysis per class in- CONCLUSIONS
dicated that external treatment is more effective in class
II–III cases in the long term. This is because in class IV 1. Treatment should not be decided only upon the re-
cases the resorption cavity is very complex and extended. sorption extent (class). Other factors such as pain
If an external approach is selected, tooth and bone tissue sensation, probing feasibility and the presence of
has sometimes to be removed to gain accessibility, com- bone-like tissue should be taken into consideration
promising the structural integrity of the tooth and its sur- as shown by clinical cases.
rounding periodontium. 2. In monitoring cases, the clinician should be aware that
Treatments containing an internal approach are less radiographical findings could be difficult to evaluate.
successful in class II and III cases, as the endodontic pro- Small changes are difficult to be quantified and to be
cedure compromises the structural integrity of the tooth understood if they are due to resorption progression or
and can potentially lead to vertical fractures. Indeed, all due to normal bone remodelling. Before the treatment
extractions from class II and III cases treated with an in- decision, this issue should be evaluated.
ternal approach were due to a vertical fracture. It should 3. The survival rate of this approach appears to be quite
be also taken into account that, in the outcome analysis promising as it is in the range of 70.3% with a mean of
of internal approach all cases had a root canal treatment. 5 years. In addition, external approaches have a better
Hopefully, in the coming years, more information on in- prognosis than internal, due to their less invasive na-
ternal approach without a root canal treatment will be col- ture. Monitoring is also a ‘safe’ option for up to 6 years
lected and evaluated by the authors. (depending on the case).
A monitoring approach is selected for cases where 4. Survival analysis per class, showed that the survival
bone ingrowth through the portal of entry hinders prob- rate of each treatment decision depends strongly on
ing of the cavity. However, the clinician should be careful the extent of the resorption. Based on the outcome of
|
Bollschweiler, E. (2003) Benefits and limitations of Kaplan-Meier

this clinical strategy, for classes II and III, an external calculations of survival chance in cancer surgery. Langenbeck's
approach is recommended, whereas for class IV moni- Archives of Surgery, 4, 239–244.
toring approach is recommended in the short-term Estevez, R., Aranguren, J., Escorial, A., de Gregorio, C., De La Torre,
(5–6 years) whereas internal approach seems to be F., Vera, J. et al. (2010) Invasive cervical resorption Class III in
more effective in the long-term. a maxillary central incisor: diagnosis and follow-up by means
5. This work aims to provide an incentive for broad col- of cone-beam computed tomography. Journal of Endodontics,
laboration between research groups and the accept- 36, 2012–2014.
European Society of Endodontology (ESE), Patel, S., Durack, C.,
ance of a universal treatment strategy in the near
Abella, F., Roig, M., Shemesh, H. et al. (2014) European Society
future of Endodontology (ESE) position statement: the use of CBCT
in endodontics. International Endodontic Journal, 47, 502–504.
ACKNOWLEDGEMENTS European Society of Endodontology (ESE), Patel, S., Lambrechts,
The authors would thank Leendert Van Nieuwenhuizen P., Shemesh, H. & Mavridou, A. (2018) European Society of
(Proclin Rotterdam) for providing images at Figure 8 and Endodontology (ESE) position statement: External Cervical
Dr. Anna Louropoulou (Proclin Rotterdam) for providing Resorption. International Endodontic Journal, 51, 1323–1326.
European Society of Endodontology (ESE), Patel, S., Brown, J.,
images at Figure 13.
Semper, M., Abella, F. & Mannocci, F. (2019) European Society
of Endodontology (ESE) position statement: use of cone
CONFLICT OF INTERESTS beam computed tomography in endodontics. International
The authors have stated explicitly that there are no con- Endodontic Journal, 52, 1675–1678.
flicts of interests in connection with this article. Gonzales, J.R. & Rodekirchen, H. (2007) Endodontic and periodon-
tal treatment of an external cervical resorption. Oral Surgery,
AUTHORS CONTRIBUTIONS Oral Medicine, Oral Pathology, Oral Radiology and Endodontics,
Study concept and design: Athina-Maria Mavridou, Paul 104, 70–77.
Gunst, V., Mavridou, A., Huybrechts, B., Van Gorp, G., Bergmans, L.
Lambrechts, Lars Bergmans Writing of the manuscript:
& Lambrechts, P. (2013) External cervical resorption: an anal-
Athina-Maria Mavridou Performed the diagnosis, treat- ysis using cone beam and microfocus computed tomography
ment and evaluation: Athina-Maria Mavridou, Paul and scanning electron microscopy. International Endodontic
Lambrechts, Dick Barendregt Analysis, visualization Journal, 46, 877–887.
and interpretation of data: Athina-Maria Mavridou, Paul Heithersay, G.S. (1999a) Clinical, radiologic, and histopathologic fea-
Lambrechts, Lars Bergmans, Eléonore Rubbers, Alexander tures of invasive cervical resorption. Quintessence International,
Schryvers, Arno Maes Critical revision: Athina-Maria 30, 27–37.
Mavridou, Paul Lambrechts, Lars Bergmans, Marcel Heithersay, G.S. (1999b) Treatment of invasive cervical resorption:
an analysis of results using topical application of trichloroace-
Linssen, Dick Barendregt.
tic acid, curettage and restoration. Quintessence International,
30, 96–110.
ETHICAL APPROVAL Heithersay, G.S. (1999c) Invasive cervical resorption: an analysis of
The study has been approved by the Clinical Trial Centre potential predisposing factors. Quintessence International, 30,
of KULeuven (registration number S54693). 83–95.
Heithersay, G.S. (2007) Management of tooth resorption. Australian
ORCID Dental Journal, 52, 105–121.
Hiremath, H., Yakub, S.S., Metgud, S., Bhagwat, S.V. & Kulkarni,
Athina-Maria Mavridou https://orcid.
S. (2007) Invasive cervical resorption: a case report. Journal of
org/0000-0002-2107-3765
Endodontics, 33, 999–1003.
Alexander Schryvers https://orcid. Irinakis, E. (2018) External cervical root resorption: determinants and
org/0000-0001-9815-8057 treatment outcomes. Master thesis. Vancouver, BC: University
of British Columbia. Available at: https://open.library.ubc.ca/
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A Clinical Approach Strategy For The Diagnosis Treatment and Evaluation of External

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Received: 5 December 2020

| Accepted: 6 January 2022

A clinical approach strategy for the diagnosis, treatment

Athina-­Maria Mavridou1,2,3 | Eléonore Rubbers1 | Alexander Schryvers1 |

Int Endod J. 2022;55:347–373. ﻿ wileyonlinelibrary.com/journal/iej | 347

I N T RO DU CT ION Indicative examples can be found in recently published

Treatment Internal External Combination Monitoring

Treatment Internal External Combination Monitoring

No info 1 2.13 1 1.09 2 2.99 15 9.74

(a) (b) (c)

Initial CBCT After 2 years

Initial CBCT After 3 years

Portal of entry (c)

(f) (g) (h)

(a) (b) (c) (d) (e) (f)

(a) (b) (c) (d)

1. Existence of pain. In this case, a monitoring approach

(a) (b) (c) (d) (e)

(f) (g) (h)

(i) (j) (k)

(a) (b) (c) (d)

(a) (b) (c) (d)

(a) (b) (c) (d)

(e) (f) (g)

(a) (b) (c) (d)

(e) (f) (g)

(h) (i) (j)

Treatment approach strategy: flowchart

Monitoring Restorave treatment Tooth removal

Evalua on of the treatment

DI S C US S I O N updated 3D classification (2018) takes under considera-

Class I Class III

Bollschweiler, E. (2003) Benefits and limitations of Kaplan-­Meier

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Athina-Maria Mavridou1,2,3 | Eléonore Rubbers1 | Alexander Schryvers1 |

Int Endod J. 2022;55:347–373. wileyonlinelibrary.com/journal/iej | 347

Monitoring Restorave treatment Tooth removal

Bollschweiler, E. (2003) Benefits and limitations of Kaplan-Meier