Management of External Invasive Cervical Root Resorption; an Interdisciplinary Approach- A Case Report

Transcription

1 Case Report AODMR Management of External Invasive Cervical Root Resorption; an Interdisciplinary Approach- A Case Report Parthiban S, Kadhiresan R, Danny Department of Periodontics, Thai Moogambigai Dental College, Chennai, Tamil Nadu, India. Address for Correspondence: Dr. Parthiban Saket, Senior Lecturer, Department of Periodontics, Thai Moogambigai Dental College, Chennai, Tamil Nadu, India. partthiban@gmail.com ABSTRACT: Invasive cervical resorption is a relatively uncommon form of external root resorptionexhibiting no external signs. The resorptive conditions is often detected by radiographic examination.the clinical features vary from a clinical attachment loss at the gingival margin to a pink coronal discoloration of the tooth crown resulting in ultimate cavitation of the overlying enamel which is painless.radiographic features of lesions vary from well delineated to irregularly bordered mottled radiolucencies,and these can be confused with dental caries. A characteristic radio opaque line generally seperates the image of the lesion from that of the root canal,because the pulp remains protected by athin layer of predentin until late in the process.histopathologically the lesion contain fibrovascular tissue with resorbing clastic cells adjacent to the dentin surface.local factors like plaque and calculus are the most frequent causes of resorption. Depending upon the extent of the resorption different treatment regimens have been proposed. In this case report asuccesfull management of maxillary central incisor with external root resorption using mineral trioxide aggregate Keywords: Cervical Root Resorption, External, Gingival Recession, Invasive, Mineral Trioxide Aggregate. INTRODUCTION: Root resorption is defined as either as a physiologic or pathologic event mainly occurring due to the action of activated clasts, it is characterized by the progressive or transitory loss of cementum. 1 Pathologic root resorption has been broadly classified based on the site of occurrence into external root resorption and internal root resorption. Invasive cervical resorption is a type of external root resorption. It is defined as a localized resorptive process that commences on the surface of the root below the epithelial attachment and the coronal aspect of the supporting alveolar process, namely the zone of the connective tissue attachment. 2 ICR is initiated apical to the epithelial attachment.it is most commonly seen in the cervical area of the tooth but it can be present anywhere in the root. 3 According to the extent of the lesion within the tooth it is classified as, class I a small invasive resorptive lesion near the cervical area with shallow penetration into 59

2 dentin, class II a well defined invasive resorptive lesion that has penetrated close to the coronal pulp chamber but shows little or no extent into interradicular dentin, class III lesions extend into the coronal third of the root as well as the coronal dentin. Class IV lesion extend the invasive process beyond the coronal third of root. 4 Different materials available for management of external tooth resorption. 5 Among the various materials MTA has gained popularity due to its biocompatibility, 6 potential of inducing osteogenesis and cementogenesis. 7 This case describes a interdisciplinary management of a maxillary central incisor with an invasive cervical resorption using white MTA as a reparative material the diagnosis, treatment and prognosis, informed consent was taken. Figure 1: preoperative discoloration CASE REPORT A 45 year old patient was presented to the department of Periodontics in Thaimoogambigai dental college Chennai, with a maxillary left central incisor with discoloration of tooth and gingival recession at the cervical area. (Figure 1) The patient has noticed discoloration and gingival recession over 3 to 4 month.after taking the past medical history of the patient it was discovered that he had undergone RTA (road traffic accident) 8 years back and the teeth remained untreated. The offending tooth was tender on percussion. The pulp vitality was tested and it was negative. The patient was referred to department of Endodontics. The radiographic examination revealed an irregular radiolucent area in the cervical third of the external root surface. (Figure 2) Periapical radiolucency was detected.the clinical diagnosis was irreversible pulpitis with classed invasive cervical resorption. The patient was informed of 60 Figure 2: Preoperative radiograph MANAGEMENT Root canal treatment and debridement and restoration of the lacunae with periodontal localized flap surgery was the treatment of choice. Endodontic management Root canal treatment was performed under local anaesthesia (lidocaine 2%.access cavity prepared on the palatal surfaces,the root canal was cleaned with manual instruments and sodium hypochlorite (NAOCL 5%) irrigation.working length was taken. Calcium hydroxide intra canal medicament was given and the access cavity was temporarily sealed and patient recalled after 7 days. After 7 days patient was recalled the canal was enlarged up with PROTAPER (DENTSPLY) and the obturation was done with help of 0.04%

3 gutta-percha (dentsply mailefer switzerland) with AH PLUS Sealer. Access cavity was restored with composite resin as the defect was on the cervical area with recession (MILLER S GRADE 1). Periodontal surgical intervention was planned to avoid post obturation flare up surgery was done 3 days after obturation Periodontal management Localized flap surgery was planned sulcular horizontal incision and vertical incision was given the region of central incisors. Full thickness flap was reflected. A circular area of resorption was clearly seen covered with granulation tissue. Complete curettage was done using (Hu freidy) curettes removing the granulation tissue efficiently. The residual cavity was refined with round bur using a slow speed motor handpiece result the defect was enlarged in size. Resorptive area was filled with MTA (PROROOT MTA Dentsply, Switzerland), the flap was repositioned and sutured. Patient was recalled after 24 hrs for checkup, suture removal was done. Patient consequently received periodontal maintenance at 4 months interval. Clinical and radiographic follow-up examination performed at 6 months, healing was statisfactory. (Figure 3) Figure 3: Perio and endodontic management and post operative radiograph DISCUSSION The aim of treating invasive cervical resorption is the complete removal of resorptive tissue and the restoration of the defect area. The present case describes an external cervical resorptive defect in which tooth shows a sign of pulpal infection and requires a multidisciplinary (endodontics 61

4 and periodontal) treatment. The etiological factor for the case report is traumatic injury. The present case can be classified as a supraosseous defect or class 3 invasive cervical resorption the communication between resorption lacuna and the root canal system was large in size and the defect was treated surgically. 8,9 Root canal treatment and management of the resorption were performed in one session in order to avoid secondary infection. In the case the resorptive area was located and debrided opening the periodontal flap and direct placement of MTA in the defect area was performed. MTA may create an environment favourable to periodontal cure and allowing the growth of cementum over its surface Mineral Tri Oxide Aggregate (MTA) was developed in 1993 by Torabinejad and coworkers to fulfill the ideal criteria of a root perforation repair material. 10 MTA is a powder which consists of hydrophilic particles of tricalcium silicate, tricalcium aluminate, tricalcium oxide, silicon di oxide. When MTA is mixed with water it becomes a colloidal gel. 11 Setting time of MTA is approximately 3-4 hrs. During the initial stage the Ph is 10.2 and later when the material was set it was White MTA was introduced in 2002 for use in aesthetic areas. 13 The clinical use of MTA in humans demonstrated its applicability in humid environment preventing bacterial infiltration and alkalization of medium on the account of presence of calcium oxide in its formulation in biologic properties similar to those of calcium hydroxide making it useful for healing the tissue CONCLUSION Tooth resorption is a perplexing problem for dental practitioners. Although the occurrence of the resorption cannot be predicted.prudent case selection and proper execution can lead to thje successful treatment and long term retention of the tooth. The use of white MTA was shown to be an excellent alternative filling in external resorptions with great destruction and communication occurred in the case with a favourable prognosis for the maintenance of tooth. REFERENCES 1. Lopes HP, SiqueiraJr JF. Endodontia. Biologia e técnica. 2. ed. Rio de Janeiro: Guanabara Koogan/Medsi; Tronstad L. Root resorption: etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988;4: Bergmans L, Van Cleynenbreugel J, Verbeken E, Wevers M, Van Meerbeek B, Lambrechts P. Cervical external root resorption in vital teeth. X-ray micro-focus tomographical and histopathological case study. J ClinPeriodontol 2002;29: Heithersay GS. Clinical endodontic and surgical management of tooth and associated bone resorption. Int Endod J 1985;18: Aqrabawi J. Sealing ability of amalgam, super EBA cement, and MTA when used as retrograde filling materials. British Dental Journal 188, (2000) Published online: 11 March Altundasar E, Demir B. Management of a perforating internal resorptive defect with mineral trioxide aggregate: a case report. J Endod 2009;35(10): Silveira FF, Nunes E, Soares JA, Ferreira CL, Rotstein I. Double pink tooth associated with extensive internal

5 root resorption after orthodontic treatment: a case report. Dent Traumatol 2009;25(3): Heithersay GS. Invasive cervical resorption:an analysis of potential predisposing factors. Quintessence International 1999;30: Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of mineral trioxide aggregate when used as a furcation perforation repair material. J Endod 1998;24(11): Mohammadi Z, Zadeh MY, Shalavi S. Non Surgical Repair of Internal Resorption with MTA: A Case report Endo D J 2012;7(4); Clasca M, Aminoshariae A, Jin G, Montagnese T, Mickel A. A comparison of the cytotoxicity and Pro-inflammatory Cytokine Production of Endosequence Root Repair Material and Proroot Mineral Trioxide Aggregate in Human Osteoblast Cell Culture using Reverse Transcriptase Polymerase Chain Reaction. Journal Of Endodontics 2012;38(4): Madfa AA, Al Sanabani FA, Al Qudami NH. Endodontic Repair Filling Materials; A Review Article. British Journal of Medicine & Medical Research 2014;4(16); Hawley M, Webb T, Goodell GG. Effect of Varying Water to Powder Ratios on the Setting Expansion of White And Grey Mineral Trioxide 14. Jacobovitz M, Lima RKP. Treatment of inflammatory internal root resorption with mineral trioxide aggregate; a case report. Int Endo DJ 2008;41(10): How to cite this article: Parthiban S, Kadhiresan R, Danny. Management of External Invasive Cervical Root Resorption; an Interdisciplinary Approach- A Case Report. Arch of Dent and Med Res 2015;1(2):