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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 40-43

Management of external cervical resorption using mineral trioxide aggregate


Department of Conservative Dentistry and Endodontics, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Submission20-Mar-2020
Date of Acceptance21-Oct-2020
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. Chinni Suneelkumar
Department of Conservative Dentistry and Endodontics, Narayana Dental College and Hospital, Chintareddypalem, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_13_20

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   Abstract 


External cervical resorption (ECR) is a relatively rare form of external root resorption, which may occur in any tooth in the permanent dentition. The etiology is usually obscure. It is characterized by its cervical location and the invasive nature; this resorptive process leads to the progressive and usually destructive loss of the tooth structure. It is often misdiagnosed, leading to improper treatment or unnecessary loss of the tooth. The article describes a case report of the ECR and its management. The salient features were a sizeable resorptive defect and localized fibrous growth located on the cervico-palatal aspect of the maxillary right central incisor. Treatment included root canal treatment, surgical exploration, and restoration of the defect with mineral trioxide aggregate. Proper diagnosis and the appropriate treatment is the key to a successful outcome in the management of ECR.

Keywords: Cone-beam computed tomography, external cervical resorption, mineral trioxide aggregate, root canal, root resorption


How to cite this article:
Himasindhu U, Suneelkumar C, Lavanya A, Swapna S. Management of external cervical resorption using mineral trioxide aggregate. J Interdiscip Dentistry 2021;11:40-3

How to cite this URL:
Himasindhu U, Suneelkumar C, Lavanya A, Swapna S. Management of external cervical resorption using mineral trioxide aggregate. J Interdiscip Dentistry [serial online] 2021 [cited 2021 May 14];11:40-3. Available from: https://www.jidonline.com/text.asp?2021/11/1/40/314174




   Key Messages/Clinical Relevance to Interdisciplinary Dentistry Top


  • The surgical management of external cervical resorption using mineral trioxide aggregate is the best alternative to extraction which also increases the longevity of the tooth
  • Cone-beam computed tomography plays an important role to detect the exact position, size, and extent of the defect.



   Introduction Top


Root resorption is a condition associated with the physiologic or a pathologic process resulting in the loss of dentin, cementum, or bone.[1] External cervical resorption (ECR) is one of the least understood types of external resorption.[2] Because of its cervical involvement and invasive property, the defect may lead to the loss of tooth structure.[3] The exact cause of the ECR is obscure.[2] It is most commonly seen in the cervical region.[4],[5],[6] Mineral trioxide aggregate (MTA) is a bioactive material that can be used for various endodontic applications.[3]

Therefore, this case report describes the management of the ECR using MTA.


   Case Report Top


A 56-year-old male patient presented to the department of conservative dentistry and endodontics, with a chief complaint of bleeding while brushing in the upper front teeth region for 3 months. The medical history of the patient was noncontributory and past dental history revealed that he had undergone trauma 6 years back while playing football. The tooth remained asymptomatic; after performing sensibility tests, it was diagnosed as pulpal necrosis.

The periapical radiograph revealed an irregular, ragged root surface on the mesial aspect of the root at cementoenamel junction and the cervical third region extending till the pulp canal and adjacent periodontal ligament space [Figure 1]a. Cone-beam computed tomographic images were also taken to confirm the exact location and extension of the lesion [Figure 1]b. This aided to arrive at the final diagnosis as pulpal necrosis with ECR.
Figure 1: (a) Preoperative radiograph; (b) Preoperative cone-beam computed tomography image; (c) Postobturation radiograph; (d) elevation of the flap

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Management

The treatment plan was to initiate root canal therapy followed by surgery and restoration of the defect. The informed consent was obtained from the patient, and the procedure was explained to the patient prior to the surgery. Under local anesthesia, the access cavity preparation was done, and working length was determined. The root canal was shaped and cleaned with manual instruments, that is, #K-files (step-back preparation) to be more conservative. Alternative irrigation was performed with normal saline and sodium hypochlorite (5.25%), with saline being the final irrigant. Later, the canal was thoroughly dried with paper points and obturated with 2% gutta-percha points and zinc oxide eugenol sealer using lateral condensation technique [Figure 1]c. As the defect was on the cervical region, surgical intervention was planned after the completion of the root canal therapy.

In the next appointment, local anesthesia was administered and horizontal sulcular incision was made from the mesial aspect of the maxillary right first central incisor. A triangular full-thickness mucoperiosteal flap was reflected and hemostasis was achieved [Figure 1]d. A significant circular resorptive defect was seen clearly from the surgical site containing granulation tissue [Figure 2]a; the resorptive area was cleaned with a rinse of normal saline.
Figure 2: (a) Exposure of the resorptive defect; (b) Restoration of the defect with mineral trioxide aggregate; (c) Flap repositioned and sutured; (d) After 4 months

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A thorough curettage of the granulomatous tissue was done and the resorption site was subsequently restored with white MTA [Figure 2]b. The flap was repositioned without tension and sutured interproximally with nonabsorbable sutures [Figure 2]c, and a final postoperative radiograph was taken. After the surgery, the patient was advised antibiotics and analgesics for a week, 0.2% chlorhexidine mouthwash twice a day for 2 weeks, and was instructed to report after a week for suture removal. When the patient reported to the department of conservative dentistry and endodontics after 4 months, he was completely asymptomatic and the tissues showed good healing in follow-up radiograph [Figure 2]d.


   Discussion Top


Root resorption of permanent dentition is usually unfavorable because it might result in irreversible damage and eventual tooth loss.[2] Its location might classify root resorption to the root surface as internal or external resorption. External root resorption can further be classified into surface resorption, external replacement resorption, external inflammatory resorption, ECR, and the transient apical breakdown.[4]

ECR of the external resorption has been described at length by Heithersay,[5],[7],[8],[9] who preferred the term invasive cervical resorption, which explains its invasive and aggressive nature. Among different causes identified, injury and stimulation by the sulcular microorganisms in adjacent marginal tissues are the reasons[10],[11] and traumatic injuries, orthodontic tooth movement, orthognathic and dentoalveolar surgery, periodontal treatment, and the internal bleaching have been reported as predisposing factors for such lesion.[7],[12]

Initially, at the early stages, it may be somewhat symmetrical, but later, the asymmetrical nature of larger lesions is more evident.[13] Many times, the lesions are misdiagnosed and confused with caries and internal resorption, resulting in inappropriate treatment.[14] In ECR, probing the resorption cavity walls with an explorer, a hard, mineralized tissue sensation will be felt, accompanied by the sharp scraping sound. This feature and appearance of the knife-edge cavity borders are essential in the differential diagnosis with root caries. Probing the ECR defect and the associated periodontal pocket will cause profuse bleeding of the underlying highly vascular resorptive tissue.[13]

The most difficult part in the diagnosis of ECR is in distinguishing this lesion from internal root resorption. The use of cone-beam computed tomography (CBCT) may be an essential diagnostic tool in this regard. This imaging technique may reveal the real extent of the resorption and its possibility of communication with the periodontal space.[15]

A successful outcome for such cases generally involves early diagnosis, elimination of the resorption, and therapeutic management. When ECR is diagnosed, usually, three choices are considered for the treatment:

  1. No treatment with the eventual extraction when a tooth becomes symptomatic;
  2. Immediate removal; or
  3. The access, debridement, and restoration of the resorptive lesion.[16]


The present report describes a case of invasive cervical resorption defect in which the tooth showed the involvement of pulp and required root canal treatment followed by sealing the resorptive area with MTA using surgical intervention.

The etiological factor for resorption in the present case seems to be a traumatic injury. Because the affected teeth remained untreated for an extended period, it would have resulted in the resorptive defect. The communication between resorption defect and the root canal system was extensive in size, and the defect was treated surgically. Surgical treatment of varying degrees of the ICR generally involves periodontal flap reflection, curettage, granulation tissue removal, and restoration of a defect with the suitable material and repositioning flap to its original position. The root canal treatment and management of resorptive defect for this case were performed in two appointments. In the present case report, zinc oxide eugenol is used for obturation because it provides better biocompatibility along with antiseptic and anti-inflammatory effects.

MTA has been shown to have excellent chemical and biological properties, and its behavior has been investigated extensively in several clinical applications.[17],[18] MTA was used as a filling material in this case because of its reported ability to provide a biocompatible surface for the possible adhesion/attachment of bone and cementum.


   Conclusion Top


Early detection with proper diagnosis can lead to successful outcome and long-term retention of the tooth. CBCT appears to be a promising diagnostic tool for confirming the presence, appreciating the true nature, and managing ECR. MTA is a potentially useful material for the repair.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Kqiku L, Ebeleseder KA, Glockner K. Treatment of invasive cervical resorption with sandwich technique using mineral trioxide aggregate: A case report. Oper Dent 2012;37:98-106.  Back to cited text no. 1
    
2.
Vijetha B, Rangappa J, Reddy SK, Aspalli N. Management of external cervical resorption using mineral trioxide aggregate. Indian J Oral Sci 2012;3:161.  Back to cited text no. 2
  [Full text]  
3.
Baranwal AK. Management of external invasive cervical resorption of tooth with Biodentine: A case report. J Conserv Dent 2016;19:296-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Patel S, Ford TP. Is the resorption external or internal? Dent Update 2007;34:218-20, 222, 224-6, 229.  Back to cited text no. 4
    
5.
Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:27-37.  Back to cited text no. 5
    
6.
Bergmans L, Van Cleynenbreugel J, Verbeken E, Wevers M, Van Meerbeek B, Lambrechts P. Cervical external root resorption in vital teeth. J Clin Periodontol 2002;29:580-5.  Back to cited text no. 6
    
7.
Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors. Quintessence Int 1999;30:83-95.  Back to cited text no. 7
    
8.
Heithersay GS. Invasive cervical resorption following trauma. Aust Endod J 1999;25:79-85.  Back to cited text no. 8
    
9.
Heithersay GS. Treatment of invasive cervical resorption: An analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999;30:96-110.  Back to cited text no. 9
    
10.
Trope M. Root resorption of dental and traumatic origin: Classification based on etiology. Pract Periodontics Aesthet Dent 1998;10:515-22.  Back to cited text no. 10
    
11.
Gold SI, Hasselgren G. Peripheral inflammatory root resorption. A review of the literature with case reports. J Clin Periodontol 1992;19:523-34.  Back to cited text no. 11
    
12.
Frank AL, Torabinejad M. Diagnosis and treatment of extracanal invasive resorption. J Endod 1998;24:500-4.  Back to cited text no. 12
    
13.
Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: A review. J Endod 2009;35:616-25.  Back to cited text no. 13
    
14.
Hiremath H, Yakub SS, Metgud S, Bhagwat SV, Kulkarni S. Invasive cervical resorption: A case report. J Endod 2007;33:999-1003.  Back to cited text no. 14
    
15.
Vasconcelos Kde F, Nejaim Y, Haiter Neto F, Bóscolo FN. Diagnosis of invasive cervical resorption by using cone beam computed tomography: Report of two cases. Braz Dent J 2012;23:602-7.  Back to cited text no. 15
    
16.
Schwartz RS, Robbins JW, Rindler E. Management of invasive cervical resorption: Observations from three private practices and a report of three cases. J Endod 2010;36:1721-30.  Back to cited text no. 16
    
17.
Witherspoon DE, Small JC, Regan JD, Nunn M. Retrospective analysis of open apex teeth obturated with mineral trioxide aggregate. J Endod 2008;34:1171-6.  Back to cited text no. 17
    
18.
Holden DT, Schwartz SA, Kirkpatrick TC, Schindler WG. Clinical outcomes of artificial root-end barriers with mineral trioxide aggregate in teeth with immature apices. J Endod 2008;34:812-7.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2]



 

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