Regenerative Endodontic Procedures for Traumatized Immature Permanent Teeth with Severe External Root Resorption and Root Perforation

External root resorption (ERR) is often a complication of traumatic injury to the teeth. Traditionally, external inflammatory root resorption is treated with calcium hydroxide. The outcome of ERR, especially replacement resorption, is unpredictable. The purpose of the present case report was to describe regenerative endodontic procedures (REPs) for 1 replanted avulsed tooth with severe external root resorption and root perforation (tooth #9) and 1 extruded tooth (tooth #8). A 9-year-old girl was referred for the treatment of teeth #8 and #9 4 months after the initial trauma. Clinical examination showed that tooth #9 had a sinus tract present near the periapical area, was tender to percussion and palpation, and did not respond to pulp sensibility tests. Tooth #8 responded to pulp sensibility tests. Periapical radiographic and cone-beam computed tomographic examination showed that tooth #9 had a periapical radiolucent lesion and severe ERRs with a root perforation. Tooth #9 was diagnosed with a necrotic pulp and symptomatic apical periodontitis. Regenerative endodontic procedures (REPs) were initiated. Tooth #8 became nonresponsive to pulp sensibility tests and developed a periapical lesion 12 months after REPs of tooth #9 and was also treated with REPs. The clinical symptoms and apical lesions resolved for both teeth after REPs. The severe ERRs were arrested, and root perforation was repaired for tooth #9. Teeth #8 and #9 underwent canal obliteration by hard tissue formation after REPs and were in function at 18 months and 30 months, respectively. REPs may be used to manage traumatized immature permanent teeth with a necrotic pulp and apical periodontitis associated with severe ERR and root perforation.     

Discontinuation of Denosumab as a Potential Cause of Generalized External Cervical Root Resorption: A Case Report

Generalized occurrence of external root resorption in an adult patient is a rare finding. This case report describes external cervical root resorption extensively affecting the dentition that may be associated with the use and subsequent cessation of denosumab for the treatment of osteoporosis.     

Management of Intruded Immature Maxillary Central Incisor with Pulp Necrosis and Severe External Resorption by Regenerative Approach

Introduction

Intrusive luxation is one of the most severe traumatic injuries of permanent teeth that may adversely affect the pulp and the periodontium. Pulp necrosis and root resorption are the main pathologic entities associated with this injury. The present report describes the endodontic management of an intruded immature maxillary central incisor presented with pulp necrosis and severe inflammatory root resorption by using the regenerative approach.

Reparative Endodontic Treatment of a Perforating Internal Inflammatory Root Resorption: A Case Report

The aim of this case report was to present a reparative treatment approach of an extensive internal inflammatory resorption with a lateral perforation and apical and lateral inflammatory lesions. Only the necrotic coronal part of the pulp was removed, and the vital pulp tissue within the resorption cavity and the apical part of the root canal was left uninstrumented. Bleeding was induced, and the blood clot was covered with mineral trioxide aggregate. Hard tissue repair and healing of the apical lesion could be observed in the 3-year recall.     

Age and Timing of Pulp Extirpation as Major Factors Associated with Inflammatory Root Resorption in Replanted Permanent Teeth

Introduction

External root resorption (ERR) is a serious complication after replantation, and its progressive inflammatory and replacement forms are significant causes of tooth loss. This retrospective study aimed to evaluate the factors related to the occurrence of inflammatory ERR (IERR) and replacement ERR (RERR) shortly after permanent tooth replantation in patients treated at the Dental Trauma Clinic at the School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Brazil.

Methods

Case records and radiographs of 165 patients were evaluated for the presence, type, and extension of ERR and its association with age and factors related to the management and acute treatment of the avulsed tooth by using the logistic regression model.

Results

The patient's age at the moment of trauma had a marked effect on the ERR prevalence and extension. The patients older than 16 years at the moment of trauma had less chance of developing IERR and RERR (77% and 87%, respectively) before the pulp extirpation, regardless of the extension of the resorption. The patients older than 11 years of age at the moment of trauma showed the lowest indices of IERR (P = .02). Each day that elapsed between the replantation and the pulp extirpation increased the risk of developing IERR and RERR by 1.2% and 1.1%, respectively, and also raised the risk of severe IERR by 0.5% per day.

Conclusions

The risk of mature teeth developing severe IERR before the onset of endodontic therapy was directly affected by the timing of the pulpectomy and was inversely proportional to age. Systemic antibiotic therapy use had no effect on the occurrence and severity of IERR in mature teeth. The occurrence of RERR before the onset of endodontic treatment stimulates further investigations of the early human host response to trauma and subsequent infection.     

Efficacy of Autologous Platelet Concentrates in Regenerative Endodontic Treatment: A Systematic Review of Human Studies

Introduction

The latest research concerns the use of platelet concentrates, which are introduced into the root canal. The aim of this study was to examine the effectiveness of platelet-rich fibrin and platelet-rich plasma in regenerative endodontics.

Root resorption in dental trauma: 45 cases followed for 5 years

Abstract –  We aimed to: (i) study the prevalence of root resorption after luxation or avulsion injuries on permanent teeth referred to our dental clinic over a 3-year period; (ii) study the relationship between type of injury and resultant type of resorption complication; and (iii) evaluate success of treatment protocols for various resorption complications. We observed 1943 patients with dental trauma, aged between 2 and 26 years, referred to the Accident and Emergency Department of the Dental Clinic, University of Brescia, from 1st September 1997 to 31st December 2001. Of these, 261 permanent teeth had sustained luxation ( n  = 188) or avulsion ( n  = 73) injuries. Permanent teeth luxation and avulsion injuries occurred most often in upper incisors (75%) of patients mostly aged 12–21 years, with males more commonly affected than females (68.3% vs. 31.7%). These cases were followed for 5 years, and complications and response to treatment were recorded. Root resorption was observed in 45 (17.24%) of these cases. Of the 45 cases with resorption, 9 were associated with luxation injury (20%) while 36 (80%) with avulsion. We distinguished 30 cases of inflammatory root resorption (18 transient and 12 progressive) and 15 cases of ankylosis and osseous replacement. When resorption was recognized, quick and effective treatment could still result in an excellent functional and aesthetic outcome for these teeth.     

Multiple Cervical Root Resorption Involving 22 Teeth: A Case with Potential Genetic Predisposition

A rare case of extensive multiple idiopathic cervical root resorption with potential genetic predisposition was presented. A heathy 19-year-old Chinese male with no contributory medical or family/social history complained of pain during mastication that lasted for several months. Oral examination identified 7 missing teeth and external cervical root resorption involving 9 teeth. Comparison of orthopantomograms taken in May 2021 and February 2022 identified that cervical root resorption occurred in 22 teeth. Resorption commenced at the cementoenamel junction and progressed rapidly over the 9-month period. Laboratory test results were within normal limits. Trio-based whole-exome sequencing showed a missense mutation c.5630 C > T in the filamin A (FLNA) gene at chromosome X of the subject. This is suggestive of the possibility of sex-linked recessive inheritance. This is the first study to report FLNA mutation in human subjects with cervical root resorption involving multiple teeth.     

Multiple Cervical Root Resorption in a Young Adult Female Previously Treated with Chemotherapy: A Case Report

Multiple idiopathic cervical root resorption is an aggressive form of external root resorption that occurs at the cementoenamel junction and can affect multiple teeth (a minimum of 3) throughout the entire dentition. Most of the individuals affected are healthy with noncontributory medical histories. The resorption is usually detected as an incidental finding on radiographs or during dental examination. This case report describes an adult female with multiple cervical root resorptions who had been treated with chemotherapy for ovarian cancer at 16 years old. Nine years later, a total of 12 teeth were diagnosed with cervical root resorption. All of the known causative factors for external cervical resorption were discarded. To our knowledge, this is the first case reported of multiple cervical root resorption related to chemotherapy.     

Ingrowth of Mineralized Tissue into the Root Canal of Immature Permanent Teeth after a Traumatic Injury: A Report of 3 Cases

The aim of this case series was to describe the endodontic management of 3 immature permanent teeth that sustained traumatic injuries and subsequently presented with complete ingrowth of mineralized tissue into the canal space. Ingrowth of bone/mineralized tissue into the canal has been considered a poor long-term outcome with an inherent risk of ankylosis. In cases 1 and 2, no endodontic treatment was undertaken, except for emergency management requiring splinting. The cases were followed for 36 and 23 months, respectively. No ankylosis was evident over the review period, and normal teeth eruption was apparent. In case 1, the tooth was treated orthodontically and was responsive to pulp sensibility testing. In both cases, there was an appearance of an internal periodontal ligament–like space on the inner root wall of the canal. In case 3, 2 years postinjury, pulp necrosis and apical periodontitis occurred, and the tooth was managed with regenerative endodontic treatment consistent with the European Society of Endodontology and the American Association of Endodontists guidelines/recommendations for a regenerative procedure. The case was followed for 8 years after regenerative endodontic treatment. No ankylosis was noted with normal eruption of the teeth. The tooth was responsive to pulp sensibility testing despite the ingrowth of mineralized tissue, which was confirmed clinically.     

Orthodontic-induced External Root Resorption of Endodontically Treated Teeth: A Meta-analysis

Introduction

The difference in the amount of orthodontic-induced external root resorption (OIERR) of endodontically treated teeth (ETT) compared with vital pulp teeth (VPT) treatment is controversial. This systematic review and meta-analysis assessed the available evidence regarding OIERR of ETT compared with VPT.

Guided Tissue Regeneration in Class IV External Cervical Resorption: A Case Report

External cervical resorption (ECR) is a type of dental resorption that originates from the loss of the cementum's protective layer. The direct exposure of dentin to the periodontal ligament may lead to the invasion of clastic cells through an entry point on the external root surface into the dentinal tissue, causing resorption. Depending on the extension of ECR, different treatments are proposed. Although the literature presents distinct materials and methods for restoring ECR areas, an existing gap is related to care in the treatment of the supporting periodontal tissue. Guided tissue regeneration (GTR)/guided bone regeneration includes the stimulation of bone formation in bone defects using different types of membranes (resorbable and nonresorbable), regardless of its association with bone substitutes or grafts. Despite the benefits of guided bone regeneration, the application of this method in cases of ECR is still under-explored in the literature. Thus, the present case report uses GTR with xenogenic material and polydioxanone membrane in a case of class IV ECR. The success of the present case is related to the correct diagnosis and treatment plan. Complete debridement of resorption areas and restoration with biodentine were effective in tooth repair. GTR contributed to the stabilization of supporting periodontal tissues. The association of the xenogeneic bone graft with the polydioxanone membrane proved to be a viable option for restoring the health of the periodontium.     

Long-term Complications of Previously Successful Regenerative Endodontic Procedures after Orthodontic Movement: A Report of 3 Different Complications after 4, 8, and 11 Years

There is a paucity of literature on late complications of regenerative endodontic procedures. The aim of this article was to report 3 cases of previously successful regenerative endodontic procedures with long-term follow-up that developed different complications after the application of orthodontic forces. In the first case, an 8-year-old female patient received a regenerative endodontic procedure in her previously intruded tooth (tooth no. 21) that had been rendered necrotic after a successful spontaneous repositioning procedure. The 5-year follow-up revealed uneventful healing, continuous root development, dentinal wall thickening, and regaining of pulp vitality for tooth no. 21. Four years later, the patient received orthodontic treatment with mild forces that lasted 2 years. The 11-year follow-up revealed severe external invasive cervical resorption, and the tooth had to be extracted. In the second case, a 6-year-old female patient suffered a lateral luxation injury in tooth no. 11. Six months after the injury, the tooth developed symptoms and discoloration and tested negative in pulp vitality testing. Single-step regenerative endodontic procedures were applied, and successful continuous root development, dentinal wall thickening, and apical closure were achieved at the 3-year follow-up. Two months after the initiation of orthodontic treatment, the tooth developed symptomatic apical periodontitis. Root canal treatment was performed to treat the disease, and the orthodontic treatment was continued. In the third case, a previously published successful regenerative endodontic procedure developed a perforating internal resorption 6 months after the application of orthodontic forces. The internal resorption was arrested with root canal treatment, the resorptive defect was repaired with bioceramic obturation, and the orthodontic treatment plan was modified. Previously successful regenerative cases might develop external invasive cervical resorption, regenerative tissue necrosis, or internal resorption after the application of orthodontic forces. Best practice/evidence-based guidelines on the appropriate orthodontic management of successful regenerative endodontic therapy teeth are lacking. Whenever possible, careful monitoring and partial or complete exclusion off orthodontic treatment might be necessary. In some cases, preventive root canal treatment before the initiation of orthodontic movement might be considered.     

External Cervical Resorption: A Volumetric Analysis on Evolution of Defects over Time

IntroductionThe aim of this study was to assess the temporal evolution of external cervical resorption (ECR) defects using a volumetric quantification method.MethodsCone-beam computed tomographic (CBCT) images of patients diagnosed with ECR who chose not to receive treatment and attended recalls were collected. ECR defects were segmented in CBCT images at baseline and recall, and their volumes were quantified. The volumetric ratio of resorption defects/teeth was calculated. Three-dimensional classification of defects at baseline and recall and the prevalence of root surface perforations ≥1 mm were determined. The Wilcoxon matched pairs signed rank test, chi-square test, and linear regression models were used to analyze the data.ResultsFifteen patients with 20 teeth diagnosed with ECR and an average recall time of 21 months were included. Nine (45%) teeth showed a change in 3-dimensional classification at recall. The volume of resorption defects (P = .0001) and the volumetric ratio of resorption defects/teeth (P = .0001) increased over time. The prevalence of root surface perforations ≥1 mm was higher at recall (n = 17, 85%) compared with baseline (n = 9, 45%) (P = .008). Linear regression models showed significant associations between the resorption defect volume at recall compared with baseline (P < .0001; 95% confidence interval, 0.053–0.081) and the volumetric ratio of resorption defects/teeth at recall compared with baseline (P < .0001; 95% confidence interval, 0.205-0.356). There was no association between the volume of resorption defects at recall with the length of the recall period, sex, or age (P > .05).ConclusionsWhen left untreated, ECR defects can increase in size and develop more root surface perforations. ECR has a dynamic nature, and its volumetric increase over time does not result from uniform/linear expansion of the defects.     

Quantitative Assessment of Root Development after Regenerative Endodontic Therapy: A Systematic Review and Meta-Analysis

IntroductionThe purposes of this review were to appraise the level of evidence of the existing regenerative endodontic therapy (RET) publications, perform a meta-analysis on the survival and healing rates of necrotic immature permanent teeth treated with RET, and run a meta-analysis on the quantitative assessment of the root development of those teeth.MethodsElectronic searches were performed in Web of Science, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Library databases. Two authors independently screened the titles and abstracts for eligibility. The analyses were performed on the clinical outcomes (ie, survival, healing, and root development) of the procedure.ResultsEleven articles were included in the qualitative and quantitative syntheses. Three studies were randomized controlled trials, 6 were prospective cohort studies, and 2 were retrospective cohort studies. The pooled survival and healing rates were 97.3% and 93.0%, respectively. The pooled rates of root lengthening, root thickening, and apical closure were 77.3%, 90.6%, and 79.1%, respectively. However, if 20% radiographic changes were used as a cutoff point, there were only 16.1% root lengthening and 39.8% root thickening.ConclusionsWithin the limitations of the present study, it can be concluded that RET yielded high survival and healing rates with a good root development rate. However, clinical meaningful root development after RET was unpredictable.     

Accuracy of Digital Periapical Radiography and Cone-beam Computed Tomography for Diagnosis of Natural and Simulated External Root Resorption

Introduction

The aim of this study was to compare the sensitivity and specificity of digital periapical radiography and cone-beam computed tomographic (CBCT) imaging in the detection of natural and simulated external root resorptions (ERRs) with micro–computed tomographic (micro-CT) imaging as the reference standard.

A Comparison of 3 Quantitative Radiographic Measurement Methods for Root Development Measurement in Regenerative Endodontic Procedures

Introduction

The outcomes of an immature tooth with necrotic pulp treated with regenerative endodontic procedures (REPs) were assessed clinically and radiographically. Root maturation is an important outcome of REPs, and several radiographic measurement methods have been used to measure this. The aim of this study was to compare radiographic measurement methods, measuring root maturation in immature teeth with necrotic pulp treated with REPs.

The Surgical Management of External Cervical Resorption: A Retrospective Observational Study of Treatment Outcomes and Classifications

IntroductionThe aims of this study were to assess the survival and clinical success of patients with teeth with external cervical resorption (ECR) who underwent surgical repair, to assess the reliability of using 2 different classification systems for ECR (Heithersay 2-dimensional classification and Patel 3-dimensional classification), and to identify if a 3-dimensional classification is a viable alternative.MethodsA retrospective study was performed in a teaching dental hospital in England. The inclusion criteria were limited to patients who underwent surgical management of ECR between 2015 and 2018. Both periapical radiographs and cone-beam computed tomographic scans of 13 patients were assessed by 2 independent dental practitioners using the Heithersay and Patel classifications. The same radiographic assessment of those records was then repeated 3 weeks later by 1 operator. These data were tested using the Cohen kappa analysis to determine inter- and intraobserver agreement.ResultsA total of 14 teeth affected with ECR were identified in 13 patients (6 women and 7 men) with a mean age of 41 years. The mean follow-up was 20 months. At follow-up, survival was noted in all cases; however, clinical success describing endodontic success, comprehensive restorative integrity, and arrest of the resorptive process was only met in 11 cases. Although helpful in describing the lesions, both classification systems displayed considerable limitations in predicting treatment outcome. A measure of Cohen kappa regarding interobserver reliability found the Heithersay classification to provide a moderate level of agreement (0.69), whereas the Patel classification provided a weak level of agreement (0.40).ConclusionsECR is a complex, aggressive, and uncommon form of external resorption. The long-term success of the treatment is predictable but strictly related to careful case selection and operative skill. In reference to ECR classifications, ambiguity still exists between their distinctive categories, leading to moderate and weak levels of interobserver agreement. Further improvement is required to enhance their use in future research.