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Table of Contents
CASE REPORT
Year : 2014  |  Volume : 4  |  Issue : 2  |  Page : 101-104

An innovative approach in management of a tooth with perforating internal resorption


Department of Conservative Dentistry and Endodontics, RGUHS, H.K.E, S. S. Nijalingappa Institute of Dental Sciences and Research Centre, Gulbarga, Karnataka, India

Date of Web Publication15-Oct-2014

Correspondence Address:
R Kaveti Hanisha
Department of Conservative Dentistry and Endodontics, RGUHS, H.K.E, S. S. Nijalingappa Institute of Dental Sciences and Research Centre, Gulbarga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.142950

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   Abstract 

Internal resorption is a rare lesion in permanent teeth. Managing perforating internal resorption is a great challenge for dentists. This report presents a successful surgical treatment of a maxillary central incisor that had an extensive root perforation due to internal resorption utilizing mineral trioxide aggregate and glass ionomer cement as perforation repair material and fiber post to reinforce the tooth strength.
Clinical Relevance To Interdisciplinary Dentistry

  • Endodontic, periodontic and prosthetic approach was done to stop resorption, for better visualization and reinforcement of tooth structure respectively.

Keywords: Fiber post, glass ionomer cement, internal resorption, mineral trioxide aggregate, perforation


How to cite this article:
Hanisha R K, Rairam S, Kumar K, Reddy P I. An innovative approach in management of a tooth with perforating internal resorption. J Interdiscip Dentistry 2014;4:101-4

How to cite this URL:
Hanisha R K, Rairam S, Kumar K, Reddy P I. An innovative approach in management of a tooth with perforating internal resorption. J Interdiscip Dentistry [serial online] 2014 [cited 2019 Nov 20];4:101-4. Available from: http://www.jidonline.com/text.asp?2014/4/2/101/142950


   Introduction Top


Resorption according to the Glossary of the American Association of Endodontists is defined as a condition associated with either a physiologic or a pathologic process resulting in loss of dentin, cementum or bone. [1] Resorption in the primary dentition is a normal physiologic process except when the resorption occurs prematurely. Resorption of permanent teeth does not occur naturally and is invariably inflammatory in nature, if untreated, this might result in the premature loss of the affected tooth. [2] Resorption may be classified based on its location in relation to the root surface as internal or external. Internal resorption is an inflammatory condition that results in progressive destruction of intraradicular dentin and dentinal tubules along the canal walls. The resorptive spaces might be filled by granulation tissue only or in combination with bone-like or cementum-like mineralized tissues. Occurrence of internal resorption when compared with external resorption is relatively rare. [3]

For internal root resorption to occur, the outermost protective odontoblast layer and the predentin of the canal wall must be damaged, resulting in exposure of the underlying mineralized dentin to odontoclasts. Various etiologic factors have been proposed for the loss of predentin, including trauma, caries, periodontal infections, excessive heat generated during restorative procedures on vital teeth, vital calcium hydroxide procedures, anachoresis, orthodontic treatment, cracked the tooth, or simply idiopathic dystrophic changes within normal pulps. [4]

Internal resorption is usually asymptomatic, the granulation tissue can clinically manifest itself as "pink spot" in cases in which crown dentin destruction is severe and is detected coincidentally through routine radiographs. Internal resorption can be found in all areas of the root canal, but is most commonly found in the cervical region. Pain or discomfort may be the chief complain if the granulation tissue has been exposed to oral fluids. [5]

Extensive internal resorption may complicate the prognosis of endodontic treatment due to weakening of the remaining dental structure and possible periodontal involvement. In modern dentistry, patients demand more than the restoration of function; they are particular about the esthetics as well, especially in the anterior region. [6],[7] The present case report shows the psychological, esthetic, functional and economic importance of maintaining the natural tooth for the patient, compared with placement of prostheses or osseointegrated implants.


   Case report Top


A 30-year-old male patient reported to the Department of Conservative Dentistry and Endodontics, H.K.E.S's

S. Nijalingappa Institute of Dental Sciences and Research, Gulbarga, Karnataka with discoloration as his chief complaint. Patient gave history of trauma and incomplete root canal treatment 16 months back. Clinical examination revealed Ellis class 1 fracture [Figure 1]a], tooth was nontender on percussion and showed grade 1 mobility. On radiographic evaluation, a resorptive area was evident in the cervical third of the tooth, and periapical radiolucency of 5 mm was observed [Figure 1]b]. Treatment options presented to the patient included perforation repair with glass ionomer cement (GIC) and mineral trioxide aggregate (MTA) followed by post and core and crown, extraction of the tooth and restoration of the site with removable partial denture, fixed partial denture and an implant-retained crown. Consequences and complications were explained to the patient. Patient decided with the treatment of perforation repair, as he would retain his natural teeth, and other options could be still pursued if this particular treatment fails.
Figure 1: (a and b) Preoperative clinical and iopa, (c) vitapex, (d) fl ap refl ection, (e) removal of resorbed part, (f) glass ionomer cement, (g) mineral
trioxide aggregate, (h) fi ber post, (i) 6 months follow-up clinical image, (j) 1-year follow-up clinical and radiographic image


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Endodontic therapy was initiated. Canal negotiation was done with no. 15 K file. Chemo mechanical preparation was done. Calcium hydroxide intracanal medicament (Vitapex, Neo Dental Chemical Product Co., Ltd., Tokyo, Japan) was placed for 3 weeks [Figure 1]c]. After 3 weeks calcium hydroxide was removed. After confirming that periapical radiolucency was subsided further treatment was carried out. Local anesthesia was administered. A full-thickness buccal and lingual mucoperiosteal flap was reflected by making an intrasulcular incision [Figure 1]d]. Hemostasis was achieved. The soft resorbed part was removed completely [Figure 1]e]. Perforation was repaired with GIC (GC FUJI II , GC Corporation, USA) [Figure 1]f] and MTA (Proroot MTA, Dentsply Tulsa Dental, Johnson City, TN, USA) [Figure 1]g]. Flap was repositioned, and sutures were placed. Sutures were removed on 7 th day. On the same day sectional obturation was done in the apical 5 mm with  Obtura II (Obtura Spartan, Fenton, MO) followed by cementation of fiber post to fortify the tooth structure (Easy post, Dentsply; , Germany) as the tooth structure was greatly weakened. Corebuid up was done with composite (Ivoclar Multicore HB flow, Ivoclar Vivadent AG, Liechtenstein) [Figure 1]h]. Splinting with fiber reinforced splint (Ribbond, Inc., Seattle, USA) had been done and was removed after 2 weeks, at 3 months evaluation, patient was asymptomatic and satisfactory. On clinical examination, tooth was firm with no other signs and symptoms [Figure 1]i]. Radiographic examination revealed reduction in the radiolucency of periapical lesion. At 6 months interval and 1-year recall clinical examination were satisfactory, and radiographic examination revealed formation of normal bony trabeculae [Figure 1]j].


   Discussion Top


Diagnosis of internal resorptions can be complex and often misdiagnosed. Various diagnostic tools used for detecting internal resorption are visual examination based on changed color in tooth crown, radiographic diagnosis, conventional and cone beam computed tomography (CBCT), light microscopy. [8] CBCT has been shown to help determine treatment complexity as well as aid the clinician in offering an accurate prognosis on the basis of the extent of the resorptive lesion.

It is important to have knowledge to distinguish between internal and external resorptions. Classically, Gartner et al. described the radiographic features of internal and external resorption. Off-angle radiographs and the use of parallel radiographic technique are advocated differentiating internal from external resorption defects. A second radiograph taken at a different angle often confirms the nature of the resorptive lesion. External resorptions will move in the same direction as the X-ray tube shift if they are lingually/palatally positioned. Conversely, they will move in the opposite direction to the tube shift if they are buccally positioned. Internal resorptions should remain in the same position relative to the canal in both radiographs. Radiologically, internal resorptions present as a cloudy, mottled, radiopaque lesion with irregular margins as a result of the presence of metaplastic hard tissue deposits within the canal. [9],[10] Differentiating internal from external resorption might be clinically challenging, especially if the metaplasia has occupied the entire resorptive cavity.

Presence of cervical caries was ruled out as there was no evidence supporting carious lesion while presence of invasive cervical root resorption was ruled out because of the history, clinical and radiographic findings. History of trauma and incomplete root canal treatment can be considered and moreover the resorption was more in the canal when compared to the external surface of the root making us think that resorption started from the root canal, ruling out other lesions and coming to a diagnosis of internal resorption with perforation. Ideally, nonsurgical treatment of perforating resorption is always advocated, however in the present case, nonsurgical intervention encountered difficulties in accessing resorptive defect as it was extending below coronal third of the root. [11]

Successful surgical and nonsurgical treatment of internal resorption in both primary and permanent teeth using MTA has been reported previously in several case reports. MTA is biocompatible and has been shown to be effective in repairing furcation perforations and lateral root perforations. The material is well-tolerated by periradicular tissues and has been shown to support almost complete regeneration of the periodontium and is osteoinductive and cementogenic. It stimulates bone coupling factors necessary for the bioremineralization and healing of osseous periapical defects. In addition, MTA has superior sealing properties when compared with other materials. [12],[13] Use of GIC as perforation repair material has been recommended in several studies as GIC has got advantages of the inherent adhesion to the tooth surface, anticariogenic property, biocompatibility, good compressive strength, ease of use, economical.

Though MTA has got many advantages and were a good perforation repair material, it had got some disadvantages like poor handling properties, long setting time, low compressive strength and chances of flushing of the material if it is in continuously in contact with saliva and GIC as such is not a very good perforation repair material when compared to MTA as it is not osteo, cemento inductive, is not having potential for regeneration of the periodontal ligament (PDL), cannot induce bioremineralisation and cannot heal any osseous defects. [13],[14],[15]

So to get promising results in the present case, GIC was used first as perforation repair material so that it inherently adheres to tooth structure, forms a barrier against which MTA will be retained, has good compressive strength, fast setting, anticariogenic and use of MTA upon it provides its benefits such as osteo-cement induction, regeneration of PDL, bioremineralisation, healing of any osseous defects, biocompatibility and good sealing property. [16]

In the present case apical 5 mm was obturated with Gutta-percha (OBTURA II), as it has improved homogeneity and surface adaptation and proved to be significantly better than lateral condensation, and then the resorption defect was reinforced with fiber post and composite core restoration re-establishing esthetics and function of the tooth. It has a low modulus of elasticity equal to that of dentin and distributes stresses thereby reducing root fractures. [17],[18]

Tooth splinting was done to enhance the stability of the tooth as the perforation was large enough to cause grade 2 mobility and weakening of the tooth.

Crown placement had inherent risk of placement of crown preparation margins on the defective site, which was repaired, and the surrounding part of the defect had a thin enamel margin which was reinforced internally with composite resin. Tooth preparation would have devoid the natural tooth structure totally of enamel, and the preparation would rest entirely on the composite material so to preserve the integrity of the tooth and retain the natural esthetics while enhancing the stability and reinforcing the tooth, fiber post and core restoration was done without crown placement.


   Conclusion Top


Several case reports have been published that represented successful surgical and nonsurgical treatment of internal resorption with MTA and GIC individually, but very less literature is available regarding the treatment of perforating resorption by use of combination of GIC and MTA. The use of biomaterials, such as MTA in conjunction with GIC in teeth with perforating internal root resorption gave optimal results, as demonstrated by clinical, radiographic examination after a follow-up of over 1-year, and this might serve as an excellent alternative to implant placement.

 
   References Top

1.Tronstad L. Root resorption: Etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988;4:241-52.  Back to cited text no. 1
    
2.Andreasen JO. Review of root resorption systems and models: Biology of root resorption and the homeostatic mechanisms of the periodontal ligament. In: Davidovitch Z, editor. Proceedings of the International Conference on the Biological Mechanisms of Tooth Eruption and Root Resorption. Birmingham UK: Ebscomedia; 1988. p. 9-21.  Back to cited text no. 2
    
3.Patel S, Pitt Ford TR. Is the resorption external or internal? Dent Update 2007;34:218-29.  Back to cited text no. 3
    
4.Yildirim S, Yapar M, Sermet U, Sener K, Kubar A. The role of dental pulp cells in resorption of deciduous teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:113-20.  Back to cited text no. 4
    
5.Silveira FF, Nunes E, Soares JA, Ferreira CL, Rotstein I. Double 'pink tooth' associated with extensive internal root resorption after orthodontic treatment: A case report. Dent Traumatol 2009;25:e43-7.  Back to cited text no. 5
    
6.Bakland LK. Root resorption. Dent Clin North Am 1992;36:491.  Back to cited text no. 6
    
7.Levin L, Trope M. Root resorption. In: Hargreaves KM, Goodis HE, editors. Seltzer and Bender's Dental Pulp. Chicago, IL: Quintessence Publishing Co. Inc.; 2002. p. 425-48.  Back to cited text no. 7
    
8.Gulabivala K, Searson LJ. Clinical diagnosis of internal resorption: An exception to the rule. Int Endod J 1995;28:255-60.  Back to cited text no. 8
    
9.Gartner AH, Mack T, Somerlott RG, Walsh LC. Differential diagnosis of internal and external root resorption. J Endod 1976;2:329-34.  Back to cited text no. 9
    
10.Patel S, Dawood A, Ford TP, Whaites E. The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J 2007;40:818-30.  Back to cited text no. 10
    
11.Hsien HC, Cheng YA, Lee YL, Lan WH, Lin CP. Repair of perforating internal resorption with mineral trioxide aggregate: A case report. J Endod 2003;29:538-9.  Back to cited text no. 11
    
12.Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP. Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: A preliminary report. J Endod 1995;21:569-71.  Back to cited text no. 12
    
13.Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: A long-term study. J Endod 2004;30:80-3.  Back to cited text no. 13
    
14.Palekar A, Maria R, Jindal V. Perforating internal resorption: Review and case reports. J Pierre Fauchard Acad 2008;22:147-51.  Back to cited text no. 14
    
15.Kenkre S. Management of perforating invasive cervical resorption: Two case reports. J Indian Acad Oral Med Radiol 2012;24:346-9.  Back to cited text no. 15
    
16.Chang YC, Lin HJ. Repairing invasive cervical root resorption by glass ionomer cement combined with mineral trioxide aggregate. J Dent Sci 2012 ;7:395-9.  Back to cited text no. 16
    
17.Anantula K, Ganta AK. Evaluation and comparison of sealing ability of three different obturation techniques-Lateral condensation, Obtura II, and GuttaFlow: An in vitro study. J Conserv Dent 2011;14:57-61.  Back to cited text no. 17
[PUBMED]  Medknow Journal  
18.Maxim S. Endodontic treatment of internal resorption with the aid of glass fibre reinforced root post. Endod Prac 2012; 52-3.  Back to cited text no. 18
    


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