ENDODONTOLOGY. Introduction. Case Report ABSTRACT

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1 Case Report Non surgical management of trauma induced external root resorption at two different sites in a single tooth with Biodentine : A case report. Vineeta Nikhil # Vipin Arora # Padmnabh Jha # Mukul Verma # ABSTRACT Effective management and appropriate treatment of external root resorption can only be carried out if the true nature and exact location of the lesion are known. This case report presents a nonsurgical endodontic management of trauma induced external root resorptions at two different sites (cervical and apical) in a maxillary lateral incisor using a bioactive dental material (Biodentine). On completion of root canal cleaning and shaping, cervical resorption defect was treated with trichloroacetic acid and granulation tissue was removed through the access cavity. Calcium hydroxide was placed as an intracanal dressing for ten days. After this period orthograde filling of the root canal space along with the resorption defects was performed with Biodentine. Fifteen months follow up review with Cone Beam Computed Tomography showed arrest of root resorption and progressive healing of the defect. Key Words: Biodentine, external root resorption, nonsurgical, trauma, trichloroacetic acid. Introduction Dental clinicians can be faced with difficult diagnostic and treatment decisions with respect to tooth resorption. Root resorption might be classified by its location in relation to the root surface, i.e., internal or external resorption. External root resorption can be further classified into surface resorption, external inflammatory resorption, external replacement resorption, external cervical resorption, and transient apical breakdown 1. External cervical resorption (ECR) is a relatively uncommon form of external root resorption which has been a source of interest and academic debate by clinicians and researchers for over a century. Currently, the etiology of external cervical resorption is poorly understood and this may explain some of the diversity in terminology as clinicians have applied varying interpretations of the underlying pathogenesis 2. This form of external resorption has been described at length by Heithersay 3-6,who preferred the term invasive cervical resorption, which describes its invasive and aggressive nature. Other terms used to describe ECR include odontoclastoma 7, peripheral cervical resorption 8, extracanal invasive resorption 9, supraosseous extracanal invasive resorption 10, peripheral inflammatory root resorption 11, and subepithelial external root resorption 12. In this # Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, Uttar Pradesh 150

2 VINEETA NIKHIL, VIPIN ARORA, PADMNABH JHA, MUKUL VERMA article it will be described as ECR, which reflects its starting point on the tooth. Several etiologic factors have been suggested that might damage the cervical region of the root surface and therefore initiate ECR. These include dental trauma 3,13, orthodontic treatment 3,14, intracoronal bleaching 3,15, periodontal therapy 3,12, and idiopathic etiology 16,17. A prerequisite for external inflammatory root resorption is damage to the normally protective cementum/cementoid which then initiates surface resorption exposing the underlying dentine to the passage of bacteria or their metabolites from the root canal to the external root surface. A normal inflammatory response ensues including the activation of clastic cells which results in resorption of both tooth and bone 18. On intra oral periapical radiographs (IOPA), ECR may be a barely discernable radiolucency or dramatically evident. The lesions vary from welldelineated radiolucencies that are quite obvious to poorly defined lesions with irregular borders and sometimes resemble caries radiographically. When ECR is superimposed in the pulp space, pulp space anatomy is usually evident 19. Various materials viz glass ionomer, light-cured resin composite, amalgam, and mineral trioxide aggregate (MTA) have been recommended to restore the resorption 20. Recently, Septodont introduced a bioactive calcium-silicate based formulation (Biodentine) which could conciliate high mechanical properties with excellent biocompatibility, as well as a bioactive behaviour. Manufacturer claim its sealing ability to be equivalent to glass-ionomers, without requiring any specific conditioning of the dentine surface. The endodontic indications of Biodentin are similar to the usual calcium silicate based materials, like the Portland cements (i.e. ProRoot MTA). However, Biodentine has some features which are superior to MTA e.g. it s consistency is better suited to the clinical use than MTA s and Biodentine does not require a two step obturation as in the case of MTA because of its faster setting time of about 12 minutes. Manuscript This case report presents the nonsurgical treatment of external cervical resorption and external apical resorption which is a possible late complication of trauma in the maxillary right lateral incisor, with Biodentine. Case Report A 28 year-old male patient was referred to the Dental College of for endodontic treatment of upper right lateral incisor and replacement of missing upper right central incisor. History revealed two episodes of trauma. First one 2 years back, when he met with an accident involving injuries of face and hand, and for that he did not receive any dental treatment. Second one a sports injury, a week back that caused avulsion of upper right central incisor and for that he got endodontic treatment of upper right lateral incisor initiated. Clinical examination revealed missing upper right central incisor and access cavity in upper right lateral incisor. No other significant clinical findings were observed. Intra oral periapical radiographs shot with parallel technique revealed a round radiolucent area in the cervical third of the external root surface and periapical radiolucent lesion with external apical root resorption in relation to upper 151

3 ENDODONTOLOGY NON SURGICAL MANAGEMENT OF TRAUMA INDUCED EXTERNAL ROOT RESORPTION AT TWO DIFFERENT SITES IN A SINGLE TOOTH WITH BIODENTINE : A CASE REPORT. right lateral incisor. In addition the IOPA also and then dampened on gauze was applied for 2 revealed the continuity of root canal outline in minutes with gentle pressure to the resorptive lesion reference to upper right lateral incisor (Fig. 1A). which was accessible through access cavity. Granulation tissue of the resorptive area was removed using a dental excavator (#18 Duflex; SS White, Rio de Janeiro, RJ, Brazil). Subsequently, calcium hydroxide (Ultracal XS; Ultradent Products Inc, South Jordan, UT) was placed as an intra canal medicament. A small cotton pallet was placed and the access cavity was temporarily sealed with Cavit G (3M ESPE, St Paul, MN). After 10 days, the root canal was re-entered Fig 1. A. Radiograph showing external cervical and external apical root resorption in maxillary right lateral incisor and empty socket of maxillary right central incisor. ECR is superimposed in the pulp space; pulp space anatomy is clearly evident. B. Working length was determined. C. complete obturation of pulp space and resorptive defects with Biodentine. Small amount of Biodentine extruded in periapical area. and irrigated alternately with 2.5% NaOCl and sterile saline to remove the temporary. The root canal was dried with sterile absorbent point. Biodentine capsule (Septodont, Saint-Maurdes Fosses, France) was mixed according to On the basis of history, clinical examination manufacturer instructions and capsule material and radiographic findings a diagnosis of ECR (class which had good creamy consistency was inserted 3 invasive cervical resorption as described by into the root canal with a MTA carrier and, was Heithersay) along with external apical root condensed with finger pluggers to fill the entire resorption in upper right lateral incisor was made canal system against along with the resorption area. and root canal treatment of upper right lateral incisor The excessive vertical condensation pressure was planned. extruded the biodentine material beyond the Access cavity was modified, and the working confines of root canal system which was although length was determined by x-ray images (Fig.1B). undesirable but patient was completely The working length was confirmed with apex asymptomatic during and after the treatment (Fig. locator ROOT ZX II (J Morita, Irvine, CA). The root 1C). It was decided to seal the access cavity with canal was instrumented with stainless steel hand the same material. After ensuring complete set of K-files until an apical stop of ISO #60 could be cement (setting time mins), the occlusion created. The persistent seeping of blood through was adjusted and the patient was discharged with the root canal diminished gradually with instructions to come for recall visit after 1 week. At instrumentation. The root canal was frequently the recall visit, the patient was asymptomatic. irrigated with 2.5% NaOCl followed by a final rinse Subsequent recalls were planned at 6-month with 5 ml of 17% EDTA. A small cotton pellet which intervals. However, the patient moved to another had been dipped into a very small quantity of a city and could not be controlled for further recall 90% aqueous solution of trichloroacetic acid (TCA) visits because of this relocation. 152

4 VINEETA NIKHIL, VIPIN ARORA, PADMNABH JHA, MUKUL VERMA When he returned after 15 months, he was asymptomatic and reported no pain or swelling during this period. On the same appointment the occlusal portion of biodentine was reduced and restored with the light cured nano hybrid composite resin Filtek Z250 XT (3M ESPE, USA). An IOPA radiograph was shot (Fig. 2D) but it was decided to carry out CBCT for better definition and three dimensional visualization of the periapical and resorptive area lesions. CBCT confirmed the formation of trabeculae and progressive healing of the defect (Fig. 2E-G). Fig 2.D. IOPA radiograph taken at 15 months recall appointment indicating healing. E-G saggital and coronal veiws showing trabeculae formation and indicating healing of lesion. Discussion Dental trauma is considered as a major potential predisposing factor in cases of invasive cervical resorption. This case is interesting from an aetiological standpoint as the patient only presented with one of the recognized predisposing factors/ causes, traumatic injury corroborating these findings. This case report describes the management of two different sites of external root resorption; these are external cervical resorption and external apical root resorption. Heithersay classified ECR according to the extent of the lesion within the tooth. The case described here can be classified as class 3 according to Heithersay 2. To best of our knowledge no case report managing external cervical resorption and external apical resorption with Biodentine has been published till date. Although it might be possible to detect resorptive lesions located on the proximal (mesial and distal) aspects of the tooth, it is much more challenging to identify confidently the true nature and extent of ECR defects located on (or which have progressed) onto the labial or palatal aspects of a tooth by using conventional radiographic techniques. The true nature of the defect can only be assessed with imaging modality like CBCT 21. Treating external cervical resorption lesions with a chemical agent, 90% TCA before the curettage of the lesion is advocated in the past 6. In the present case, effort was made to assure complete elimination of granulation tissue during chemomechanical root canal preparation and by application of TCA. One advantage of this approach is haemorrhage control which otherwise can prove a problem with conventional treatment. As the effect of TCA is to cause coagulation necrosis, the resorptive tissue is rendered avascular. In addition as there is a tendency for recurrence of this type of resorption, the inactivation of adjacent and potentially resorptive cells by TCA is a further reason for its utilization. Afterward, the resorption defect was filled with Biodentine by orthograde access. Several new calcium silicate based materials have recently been developed 22-25, aiming to improve some MTA drawbacks such as its difficult handling property 22 and long setting time 23,24. Biodentine is amongst these materials and is claimed to be used as a dentine restorative material in addition to endodontic indications similar to 153

5 NON SURGICAL MANAGEMENT OF TRAUMA INDUCED EXTERNAL ROOT RESORPTION AT TWO DIFFERENT SITES IN A SINGLE TOOTH WITH BIODENTINE : A CASE REPORT. those of MTA. Biodentine powder is mainly composed of tricalcium silicate, calcium carbonate and zirconium oxide as the radio-pacifier, whilst Biodentine liquid contains calcium chloride as the setting accelerator and water reducing agent. It is interesting to note that Biodentine has the capacity to develop watertight interfaces both with dental structures and with adhesive systems. Déjou et. al. 25 concluded that the marginal sealing of Biodentine without any surface treatment or adhesive system was equivalent to that of the Z250- Optibond solo plus adhesive restorative system. In spite of the acidic ph of the artificial saliva, the new material showed no erosion and an increase in the compressive strength. Biodentine shows apatite formation after immersion in phosphate solution indicative of its bioactivity. The deposition of apatitic structures might increase the marginal sealing of the material. These physico-chemical properties associated with the biological behavior suggest that it may be used as a permanent dentine substitute. The use of MTA as an obturation material is already mentioned in dental literature 20. Filling of entire root canal along with resorptive defects with Biodentine was chosen because perforation repair, root-end induction, and root-end filling are essentially forms of partial canal obturation and the orthograde filling of the apical region or the entire root canal system with biodentine is the next logical progression in the evolutionary application of this material, especially in regards to replacing lost dentin with a dentin like material after removal of pulp and dentine during biomechanical preparation or any pathologic resorption. The use of biodentine as an obturation material might ultimately provide long-term benefits that enhance the prognosis and retention of the natural dentition in conventional and complex therapies. One of the limitations is difficulty in removal of this material in case of retreatment. Also compared to MTA, Biodentin has a better consistency after mixing which allows ease of placement in areas of resorptive defect or obturation of full root canal system. Nonsurgical approach is always a first choice for the treatment of any disease. Orthograde treatment with biodentine in management of external root resorption resulted into healing of the defect. In present case Biodentine cement extruded beyond the apex. As mentioned in literature, extruded MTA should not affect the outcome 20, similarly the present case showed that extruded biodentine did not affect periapical healing. However the clinicians should always pack the material cautiously to prevent extrusion. Conclusion This case report presents a favourable clinical outcome when Biodentine was used for treating external cervical resorption, external apical resorption and obturating root canal. However, further studies are necessary to provide more information about the use of Biodentine for the treatment of resorptive defects and obturation of pulp space. References : 1. Patel S, Pitt Ford T. Is the resorption external or internal? Dental Update 2007;34: Heithersay GS. Invasive cervical resorption Endodontic Topics 2004; 7:P Heithersay GS. Clinical, radiologic and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:

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