Conservative Nonsurgical Treatment of

Class 4 Invasive Cervical Resorption: A Case

Series

Stefano Salzano, DDS, and Federico Tirone,

DDS

Journal of Endodontics 2015

RESORPTION

 A condition associated with either a physiologic

or a pathologic process that results in loss of
substance from a tissue such as dentin, cementum
or alveolar bone . (American Association of
Endodontists 1984)

2
CLASSIFICATION BY AAE
1.Internal resorption
 Root canal (internal) replacement resorption
 Internal inflammatory resorption

2. External resorption
 Surface resorption
 Inflammatory root resorption
 Cervical resorption
 Replacement resorption /Ankylosis

3
EXTERNAL CERVICAL ROOT RESORPTION
Definition

 External cervical resorption(ECR) is defined as a localized

resorptive process that involves the surface of root below
epithelial attachment and coronal aspect of the supporting
alveolar process that is characterized by invasion of the
root by fibrovascular tissue derived from the periodontal
ligament (Heithersay 1999)

4
ETIOLOGY

 Injury to the attachment apparatus (periodontal

ligament or cementum) immediately below the
epithelial attachment of the root

 Orthodontic tooth movement (21%)

 Dental trauma (14%)
 Non-vital bleaching (5%)
 Bruxism (0.9%)
 Periodontal therapy(11%)

(Cohen 11th edition)

5
 Source of stimulation (infection)

 bacteria in the sulcus of the tooth

 periodontal infection
 Clinical evaluation
 Asymptomatic

 Pulp tests are vital

 Clinically a pink spot may be observed

cervically. (Heithersay 2004, Patel &
 itt Ford 2007).

 The resorptive lacunae can be probed through

the gingival sulcus and may be observed to
extend coronally under the enamel.

 Probing may result in profuse

bleeding --presence of inflamed tissue rather
than normal attachment 8
Radiographic appearance

 ECR in the resorptive phase will be radiolucent

in nature.
 Lesions may be symmetrical or asymmetrical,
their margins vary from being well defined and
smooth to ragged .
Defect could be misdiagnosed as root caries
But pulp vital in these cases
The radiolucency expands coronally and apically
in the dentin, but usually does not perforate
the root canal

9
DIAGNOSTIC FEATURES OF EXTERNAL ROOT
RESORPTION

LESIONS DUE TO EXTERNAL RESORPTION SHIFT ON

CHANGING THE ANGULATION

10
 CASE 1

A 46-year-old female patient

undergoing an invisible orthodontic
treatment reported a feeling of
discomfort on tooth 14.

The periapical radiographs showed

a radiolucent lesion extending from
the cervical level up to the middle
third of the tooth.
CBCT section showing that
resorption is palatal and
close to root canal
Clinical procedure

Cleaned cavity showing the

distopalatal perforation
 Before filling the resorptive
defect with MTA, a paper point
was inserted into the canal to
prevent cement from sliding
downward (Fig. 1D).

 MTA was left in place for 24

hours in touch with a cotton
pellet moistened .

 The access cavity was

temporarily sealed with Cavit
(3M Espe, Seefeld, Germany).
Radiograph taken after Follow up radiograph after
obturation with 18 months no signs of ECR
thermafil. relapse or periradicular
lesion
 CASE 2

Periapical radiograph Bitewing radiograph taken

showing the lesion 1 year later showing depth
extent upto the middle of lesion surrounding the
third root canal
Cleaned cavity showing
the pronounced thinness Tooth filled with MTA upto apex
of the distal cervical wall ,
which is the starting point
of ICR onset
Final radiograph Follow up radiograph
showing condensed after 12 months
MTA
 CASE 3

3
DISCUSSION

 It is undeniable that ECR is difficult to diagnose for 2

main reasons:
 first, its course is almost always asymptomatic,
and second, class 1 and class 2 lesions are difficult to
detect because they may be confused with either
carious lesions or radiolucency depending on the
radiographic projection.

 Therefore, diagnoses of ECR need to be confirmed

by CBCT imaging.
 A clinical study compared Periapical radiographs(PR) and
CBCT for the detection and management of internal and
external cervical resorption lesions (Patel et al. 2009).

 This study not only confirmed the superior accuracy of

CBCT over PR, but also that the correct treatment plan was
more likely to be chosen when the clinician had access to
CBCT.

 Similar conclusions have been found in more recent in -vivo

study. (Ee et al . 2016,).

 In all of the cases described in this article, the hypothesis of

removing the granulomatous tissue without performing the canal
treatment was not advisable.
There is no doubt that a surgical approach would
be more invasive, not only for patients but also in
terms of tooth loss.

 Furthermore, it is known that it is often impossible

to provide an optimal access to the surgical
treatment of ECR.

 In cases 1, 2, and 3, surgical access would have

been difficult given the depth and the position of
the resorptions located in the palatal/lingual area.
 The outcome would have been a higher loss
of tooth structure in the coronal area.

 Furthermore, it would have been very

difficult to perform the root canal treatment
and the surgical treatment of ECR at the same
time. The approach described in this case
series enables achieving both goals without
surgery.
 The use of MTA and dentin substitutes such as Biodentine
seems to be the best choice to fill the resorptive cavities.

 In addition, the alkaline pH will down-regulate osteoclastic

function and up-regulate osteoblastic activity (Narita et al.,
2010)

 Bogen and Kuttler et al (2009) have showed that MTA can

be used as an obturating material in complex situations
cases such as teeth with open apices, perforations, and
resorptions.
 Biodentine has been used as a favourable repair material
due to its bioactivity and biocompatibility.

 It has a setting time of of less than 12mins excellent

sealing ability.

 Its property to release calcium ions and enhancing the

alkaline environment makes biodentine more conducive
for osteoblastic activity.

 Also calcium and hydroxide ions stimulate the release of

pyrophosphatase, alkaline phosphatase, and BMP-2,
which favours the mineralization process.
 Conclusion

The use of Biodentine to treat ECR in nonsurgical

approach provides clinical advantages compared with
that of MTA.

 It enables the endodontist to perform a treatment

including composite resin filling within a single session.

Furthermore, Biodentine has a lower influence on the

color gradient acquired by the cervical third of the
tooth compared with MTA, even in its white version.
Conservative Management of Class 4 Invasive
Cervical Root Resorption Using Calcium-
enriched Mixture Cement- A Case Report

Saeed Asgary, DDS, MS,* and Ali Nosrat, DDS,

MS, MDS*†

Journal of Endodontics 2016

 INTRODUCTION

 Class 4 invasive cervical root resorption (ICRR)

presents a treatment dilemma in endodontics.

 The widely accepted treatment options for a class 4

ICR are to leave these teeth untreated for as long as they
are asymptomatic or extraction.

 Almost all treatment approaches (surgical or non-

surgical) have unfavorable outcome due to either
extensive damage to the periodontal tissues or inability
to stop the resorption.
 This article presents successful management of
a case of class 4 invasive cervical resorption
using a novel noninvasive nonsurgical approach.

A bioactive cement, Calcium enriched mixture

(CEM) cement, was used as obturation material
to stop the resorption and induce healing in
periodontal tissues.
Case 1

(A)A preoperative image of tooth

42 provided by the referring
dentist.

(B)The radiograph shows class 4

ECR in the coronal third and
midroot area, perforation of the
root because of resorption, a
crestal bony defect adjacent to
the perforation, and a small
periapical lesion.
 (B) A preoperative image of
tooth 42 at the initial visit.

The access cavity prepared by

the referring dentist left open to
the oral cavity and radiopaque
material in the root canal space
determined to be a piece of
gutta-percha.

The endodontic diagnosis for tooth was

previously initiated treatment with
asymptomatic apical periodontitis.
 CLINICAL PROCEDURE

After local anesthesia was obtained using a labial and

lingual infiltration , the tooth was isolated with a rubber
dam.

The patency of the root canal space was confirmed using a

size 15 K-file

The working length was determined radiographically. Root

canal preparation was first performed using rotary
instruments (ProTaper Universal files size S1 to F2, Dentsply
Maillefer) and then hand filing to an apical size of #35.
 An errant piece of gutta-percha was retrieved from the
root canal space, which was consistent with the
radiopaque material observed in the initial radiograph.

Root canal space was irrigated with sodium hypochlorite

2.5% (10 mL) in between each instrument. Bleeding
subsided as the cleaning and shaping of the root canal
progressed. Finally, the root canal space was irrigated with
3 mL 17% EDTA to remove the smear layer.

CEM cement (BioniqueDent, Tehran, Iran) powder

and liquid were mixed according to the
manufacturer’s instructions.
 CEM cement was delivered incrementally using the
MAP system (Produits Dentaires SA, Vevey,
Switzerland).

A moist cotton pellet was placed on the CEM cement, and

the access cavity was restored temporarily (Cavite; Asia
Chemi Teb Co, Tehran, Iran). A day later the access cavity
was restored with a composite resin (3M ESPE, St Paul,
MN).
(C) A postoperative image of tooth
42 after the coronal restoration was
performed using CEM cement
(D) The 24-month follow-up
radiograph.
There was no progression of the
resorptive process; and the
periapical lesion had healed.
 CASE 2

Figure 2 Case 2. (A) Periapical radiograph showing a thin longitudinal radiolucent area parallel to the nerve of tooth #44. (B)
CBCT coronal section highlighting the vestibular location of the defect. (C) Cleaned cavity connected with the vestibular
periodontium. (D) Defect filling with CEM. (E) Final radiograph taken after filling the root canal with CEM. (F) Follow-up
radiograph taken 10 months later.
 DISCUSSION

As shown by Heithersay , the success rate for the

treatment of class 4 ECR is 12.5%.

The traditional technique was to surgically expose the

resorptive defect, curette the resorptive lesion, and
apply a 90% aqueous solution of trichloroacetic acid to
remove all of the resorptive tissues that remained in the
dentinal structure.

Recently, a conservative nonsurgical approach for

treatment of class 4 ICRR has been introduced by
Salzano and Tirone et al.
The authors suggested mechanically removing the resorptive
lacuna through an access cavity and sealing the entire cavity
with MTA.

In the presented case, there was sufficient size of the access
to remove the resorptive lesion through the access cavity.

 After complete chemomechanical preparation of the root

canal, the entire canal space and perforation area were filled
with calcium-enriched mixture cement.
 CEM cement is a bioactive material and releases calcium
hydroxide after setting .

 Studies have shown that alkalinization of root dentin is

important to reverse the acidic environment necessary for
continuation of a resorptive process occurring by
osteoclastic or odontoclastic action .

 Sustained release of calcium hydroxide by CEM cement

can change the pH in the resorptive lacuna.
 Saeed et al stated that in comparison with Calcium
hydroxide, CEM cement has shown more favorable
biocompatibility and the potential to induce hard tissue
formation.

 They showed that one of the disadvantages of using a

calcium silicate–based cement as an obturation material is
the presence of voids and inadequate filling of difficult-to-
access parts of the root canal system.

 However, complete osseous healing of the periapical lesion

confirms that this technical deficiency does not have
biological consequences for the long-term outcome of the
treatment.
 Another technical challenge in obturation of root
canals with resorption-related perforations is to control
the bleeding.

 However like MTA, CEM cement is a bioactive

material that sets in the presence of moisture .

 Asgary et al. reported successful management of

inflammatory external root resorption using CEM
cement.

 The long-term effect of blood contamination on the

clinical outcome of CEM obturation is yet to be
studied.
 CONCLUSION

The favorable outcome in this cases of class 4 ECR

treated with CEM cement suggests that other cases of
severe cervical resorption may be candidates for
treatment with CEM cement rather than with traditional
methods that include surgery and the potential for
destruction of healthy periodontal tissues.

More clinical studies with large sample sizes are

recommended to compare the long-term outcome of this
treatment.
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