Mineral trioxide aggregate in the treatment of external invasive resorption: a case report

AIM: To describe the management of external invasive resorption using mineral trioxide aggregate (MTA). SUMMARY: External invasive root resorption may occur as a consequence of trauma, orthodontic treatment, intracoronal bleaching and surgical procedures, and may lead to the progressive and destructive loss of tooth structure. Depending on the extent of the resorptive process, different treatment regimens have been proposed. A 19-year-old male patient presented with tooth 11 (FDI) showing signs and symptoms of irreversible pulpitis, external invasive resorption and periodontal pocket on the disto-palatal. After root canal treatment, the defect was accessed coronally. The resorption area was chemo-mechanically debrided using ultrasonic tips and irrigant solution. MTA was used to fill the resorptive defect, and the coronal access was temporarily sealed. The definitive coronal restoration was performed after 3 days. Radiographs at 1, 2 and 4 years showed adequate repair of the resorption and endodontic success. Clinically, the tooth was asymptomatic, and no periodontal pocket was found. KEY LEARNING POINTS: *Mineral trioxide aggregate was successfully used to restore a small area of external invasive resorption. *A coronal approach can sometimes be successfully used in order to avoid surgery and periodontal complications.     

Reverse sandwich restoration for the management of invasive cervical resorption: a case report

Introduction

Invasive cervical resorption (ICR) may occur as a consequence of trauma, orthodontic treatment, intracoronal bleaching, and surgical procedures and may lead to the progressive and destructive loss of tooth structure. The restoration of these resorptive defects is a challenging task because no single restorative material possesses good sealing ability, reinforcement of remaining tooth structure, and biocompatibility simultaneously.

Methods

This case presented with invasive cervical resorption class 2 (Heithersay) and apical inflammatory resorption caused by trauma in tooth #9. The surgical management of ICR was performed, and, finally, the roots were externally reinforced by filling the resorptive defect with a combination of composite and resin-modified glass ionomer cement, proposed as reverse sandwich restoration (RSR).

Results

This novel RSR was well tolerated by the periodontal tissues. A follow-up x-ray showed no pathological changes and no recurrence of resorption.

Conclusions

This case report presents a treatment strategy for root reinforcement that might improve the healing outcomes for patients with invasive cervical resorption.     

Invasive cervical resorption: clinical and radiological diagnosis and treatment of 3 cases

Invasive cervical resorption is a relatively uncommon form of external root resorption. Etiologic factors include trauma, orthodontic treatment, intracoronal bleaching, and inflammation, but invasive cervical resorption is often idiopathic. There may be no external signs of this disorder, and the resorptive lesion is often detected by routine radiographic examination. This article describes the clinical and radiological diagnoses and treatment modalities of invasive cervical resorption in 3 patients. Two of the 3 cases were incidental radiographic findings and the teeth concerned were symptom free. One case was symptomatic due to periodontal infection. Computed tomography (CT) evaluation was performed in the 2 symptom-free patients. Thus, exact size and localization of the resorptive lesions were obtained. In 2 cases, root canal treatment was performed, and in the other case the resorptive defect was sealed with mineral trioxide aggregate.     

Invasive cervical resorption: a case report

Invasive cervical resorption (ICR) is a relatively uncommon form of external resorption, which may occur in any tooth in the permanent dentition. Characterized by its cervical location and invasive nature, this resorptive process leads to progressive and usually destructive loss of the tooth structure, the clinical features of which often resemble internal resorption ("pink tooth"). This article describes a case report of ICR and its management. The salient features were a large resorptive defect and localized fibrous in-growth located almost wholly on the cervicolabial aspect of the maxillary incisor crown involving the enamel and dentin.     

Histometric study of root resorption on human premolars following experimental replantation

Abstract – A histometric method was applied for evaluation of root resorption in 57 experimentally replanted teeth and 22 controls. Representative axiobuccolingual sections were selected for measurement of resorptions at a magnification of × 40. The frequency of root resorption in the control teeth was low. In replanted teeth marked resorptive activity elicited by the trauma appeared after 2 wk. The extent of active resorptions increased until the third postoperative week. On an average 14% of the root periphery was affected at this stage. After the sixth postoperative week progressive cement deposition took place in the resorption lacunae. Incidental ankylosis of the periodontal membrane also occurred from this observation time but there was no increase among the long-term groups.     

Histometric study of root resorption on human premolars following experimental replantation

A histometric method was applied for evaluation of root resorption in 57 experimentally replanted teeth and 22 controls. Representative axiobuccolingual sections were selected for measurement of resorptions at a magnification of x 40. The frequency of root resorption in the control teeth was low. In replanted teeth marked resorptive activity elicited by the trauma appeared after 2 wk. The extent of active resorptions increased until the third postoperative week. On an average 14% of the root periphery was affected at this stage. After the sixth postoperative week progressive cement deposition took place in the resorption lacunae. Incidental ankylosis of the periodontal membrane also occurred from this observation time but there was no increase among the long-term groups.     

Root resorption – diagnosis, classification and treatment choices based on stimulation factors

Abstract –  Etiology of different types of root resorption requires two phases: mechanical or chemical injury to the protective tissues and stimulation by infection or pressure. Injury can be similar in various types of root resorption. The selection of proper treatment is related to the stimulation factors. Intrapulpal infection is the stimulation factor in internal root resorption and external periradicular inflammatory root resorption. Adequate root canal treatment controls intrapulpal bacteria and arrests the resorption process. In cervical root resorption, infection originates from the periodontal sulcus and stimulates the pathological process. As adequate infection control in the sulcus is unlikely, removal of granulation tissue from the resorption lacuna and sealing are necessary for repair. Removal of the stimulation factor, i.e. pressure, is the treatment of choice in root resorption related to pressure during orthodontic treatment, or an impacted tooth or tumor. In ankylotic root resorption, there is no known stimulation factor; thus, no predictable treatment can be suggested. Therefore, various types of root resorptions can be classified according to the stimulation factors: pulpal infection resorption, periodontal infection resorption, orthodontic pressure resorption, impacted tooth or tumor pressure resorption, and ankylotic resorption.     

Identification of factors associated with pathological root resorption in traumatized primary teeth

Abstract – The aim of this study was to determine the factors associated with the development of pathological root resorptions in traumatized primary teeth. Based on Dental Reports on Traumatism from the Assistance Program for the Traumatized Patient, 90 children were selected. Among these children, 45 did not present pathological root resorption, while 45 did (23 replacement root resorptions and 22 external inflammatory root resorptions). Possible factors associated with the development of the pathological resorption include: (i) over 18 months or over 52 months of age, (ii) complicated trauma, and (iii) presence of more than one trauma in the same tooth. Using the chi-squared test, it was verified that trauma recurrence was considered to be a factor associated with the development of pathological root resorption (χ² = 3.636; P  < 0.05). Through the univaried logistic regression test, it was revealed that children with trauma recurrence present a 2.6 times higher chance of developing pathological root resorptions when compared with children that did not report trauma recurrence. Through the univaried logistic regression test, it was also observed that the association of two or three factors caused the chances of pathological root resorption development to increase by 3.8 times in 18-month-old children or older (95% CI: 1.5–9.7) and by 5.1 times in 52-month-old children or older (95% CI: 1.5–17). Trauma recurrence in the same primary tooth is associated with pathological root resorption, and the interaction among two or three factors increases the chance of developing such sequelae.     

Endodontic-orthodontic relationships: a review of integrated treatment planning challenges

Literature review There is a paucity of information on the concise relationship between endodontics and orthodontics during treatment planning decisions. This relationship ranges from effects on the pulp from orthodontic treatment and the potential for resorption during tooth movement, to the clinical management of teeth requiring integrated endodontic and orthodontic treatment. This paper reviews the literature based on the definition of endodontics and the scope of endodontic practice as they relate to common orthodontic-endodontic treatment planning challenges. Literature data bases were accessed with a focus on orthodontic tooth movement and its impact on the viability of the dental pulp; its impact on root resorption in teeth with vital pulps and teeth with previous root canal treatment; the ability to move orthodontically teeth that were endodontically treated versus nonendodontically treated; the role of previous tooth trauma; the ability to move teeth orthodontically that have been subjected to endodontic surgery; the role of orthodontic treatment in the provision for and prognosis of endodontic treatment; and, the integrated role of orthodontics and endodontics in treatment planning tooth retention. Orthodontic tooth movement can cause degenerative and/or inflammatory responses in the dental pulp of teeth with completed apical formation. The impact of the tooth movement on the pulp is focused primarily on the neurovascular system, in which the release of specific neurotransmitters (neuropeptides) can influence both blood flow and cellular metabolism. The responses induced in these pulps may impact on the initiation and perpetuation of apical root remodelling or resorption during tooth movement. The incidence and severity of these changes may be influenced by previous or ongoing insults to the dental pulp, such as trauma or caries. Pulps in teeth with incomplete apical foramen, whilst not immune to adverse sequelae during tooth movement, have a reduced risk for these responses. Teeth with previous root canal treatment exhibit less propensity for apical root resorption during orthodontic tooth movement. Minimal resorptive/remodelling changes occur apically in teeth that are being moved orthodontically and that are well cleaned, shaped, and three-dimensionally obturated. This outcome would depend on the absence of coronal leakage or other avenues for bacterial ingress. A traumatized tooth can be moved orthodontically with minimal risk of resorption, provided the pulp has not been severely compromised (infected or necrotic). If there is evidence of pulpal demise, appropriate endodontic management is necessary prior to orthodontic treatment. If a previously traumatized tooth exhibits resorption, there is a greater chance that orthodontic tooth movement will enhance the resorptive process. If a tooth has been severely traumatized (intrusive luxation/avulsion) there may be a greater incidence of resorption with tooth movement. This can occur with or without previous endodontic treatment. Very little is known about the ability to move successfully teeth that have undergone periradicular surgical procedures. Likewise, little is known about the potential risks or sequelae involved in moving teeth that have had previous surgical intervention. Especially absent is the long-term prognosis of this type of treatment. During orthodontic tooth movement, the provision of endodontic treatment may be influenced by a number of factors, including but not limited to radiographic interpretation, accuracy of pulp testing, patient signs and symptoms, tooth isolation, access to the root canal, working length determination, and apical position of the canal obturation. Adjunctive orthodontic root extrusion and root separation are essential clinical procedures that will enhance the integrated treatment planning process of tooth retention in endodontic-orthodontic related cases.     

Identifying early osteoclastic resorptive lesions in feline teeth: a model for understanding the origin of multiple idiopathic root resorption

Background and Objective:  Domestic cats commonly suffer from external osteoclastic tooth resorption, a disease with many similarities to human multiple idiopathic root resorption. In both diseases, it is unclear whether anatomical features of the tooth surface are associated with a predisposition for resorptive lesions. The aim of the present study was to investigate the origin and progression of early feline osteoclastic resorptive lesions in teeth exhibiting no clinical signs of disease.
Material and Methods:  The entire surfaces of 138 teeth from 13 adult cats were analysed using back-scattered electron microscopy. The distribution of lesions was assessed by tooth type, location and between individuals.
Results:  Seventy-three (53%) teeth showed at least one resorptive lesion. Eleven (85%) cats had lesions, and there was a significant association between increasing age and incidence of resorptive lesions. The highest frequency occurred in mandibular molars (82%). On average, there were 3.5 lesions per tooth. Fifty-two (38%) teeth featured resorptive lesions at the cemento–enamel junction. Twenty-three per cent of teeth with resorptive lesions showed evidence of repair of lesions that was limited to the root surface. There was no evidence of repair of resorptive lesions at the cemento–enamel junction.
Conclusion:  Resorption is prevalent without evidence of clinical disease, and occured at younger ages than previously reported. It can initiate anywhere on the root surface, but lack of repair of lesions at the cemento–enamel junction indicates that mechanisms of replacement are absent or compromised in this region. Whereas resorption of the root may undergo repair, resorption at the cervix may progress to clinically evident lesions.     

Root resorptions in upper first premolars after application of continuous intrusive forces

A scanning electron microscopy study of possible root resorptions and their localization after application of continuous forces of different magnitudes was conducted. Twelve upper first premolars, indicated for extraction, were previously intruded with constant forces. The teeth were divided into 3 groups: 1. non-moved control teeth, 2. continuous force application of 50 cN for 4 weeks, 3. continuous force application of 100 cN for 4 weeks. Specially designed NiTi-SE-stainless steel springs were utilized to exert the actual forces. After experimental tooth movement, the extracted teeth were dehydrated, metal-coated and examined by scanning electron microscopy. The intruded teeth showed resorptive areas consisting of lacunae (concavities) in the mineralized root surface. The teeth moved with 50 cN showed in the apical third several, in the medial third few, and in the cervical third no resorptive areas. In the case of the teeth moved with 100 cN, we observed resorptive areas in most of the apical third—including the apex contour—, several in the medial third, and none in the cervical third. In the control group no resorptions were observed. Thus, our results suggest that intrusion of human teeth with continuous forces induces root resorption, depending on the magnitude of force applied.     

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.     

Root resorption.

Several types of resorption affect teeth: internal, external, invasive, pressure, and idiopathic resorption. Diagnosis depends on an accurate medical and dental history, and radiographic and clinical examination. Because trauma appears to be a major factor associated with resorption, questions regarding past traumatic events may provide good leads to a likely cause. Treatment is determined based on a correct diagnosis. Root canal therapy is very beneficial in cases of internal resorption and external, inflammatory resorption. In cases of invasive resorption, it may or may not be necessary, whereas in replacement and pressure resorption, root canal therapy is not indicated at all (unless unrelated pulpal conditions necessitate endodontic intervention). Prevention of resorption includes appropriate treatment of traumatically injured teeth with frequent evaluation visits during the first year following an injury. Early detection of pressure-producing agents such as cysts, tumors, and impacted teeth can allow timely treatment to minimize the resorptive destruction.     

Orthodontically induced inflammatory root resorptions: a case report

Abstract –  Orthodontically induced inflammatory root resorption is an unfortunate consequence of orthodontic movement. It is an adverse effect of an otherwise predictable force application. The degree of the inflammatory process depends on various factors such as amount of force, bone quality, aggressiveness of the resorbing cells and individual variation. Orthodontists should keep track of tooth movement both clinically and radiographically in order to detect any root resorptions and reevaluate the case. This case report presents the treatment outcome (4-year follow up) of five teeth with different and extensive inflammatory root resorptions following orthodontic treatment.     

Root resorption after orthodontic treatment in high- and low-risk patients: analysis of allergy as a possible predisposing factor

The development of excessive root resorption during orthodontic tooth movement is an adverse side-effect, which is of great concern. The aim of this investigation was to analyse factors that might be associated with orthodontically induced root resorption. After buccal movement of maxillary premolars in 96 adolescents, the experimental teeth were extracted and subjected to histological analysis and measurement of resorbed root area. Fifty individuals, 18 boys and 32 girls, mean age 13.4 years, were selected and divided into two equal groups: the high-risk group based on measurements of the most severe root resorptions, and the low-risk group on measurements of mild or no root resorptions. After a preliminary screening of possible risk factors regarding root resorption, i.e. root morphology, gingivitis, allergy, nail-biting, medication, etc., only those subjects with allergy showed an increased risk of root resorption, but this was not statistically significant.     

Treatment of invasive cervical resorption with sandwich technique using mineral trioxide aggregate: a case report

This article presents two cases of large invasive cervical resorption (ICR) with maintenance of pulp vitality after treatment with mineral trioxide aggregate (MTA) in a sandwich technique.Invasive cervical resorption is a relatively uncommon but aggressive form of external resorption, primarily caused by dental trauma or injury of the cervical periodontal attachment. The resorptive process does not penetrate into the root canal, and the pulp is not involved in the first phase of the resorption. This feature differentiates external resorption from internal resorption. In most cases, invasive cervical resorption is found during routine radiographic or clinical examination. Different materials have been proposed for the treatment of external cervical resorption. Therapy can be effective when it 1) removes the etiological factors and 2) interrupts the progressive resorption mechanism.The key learning points of this article are the following: treatment strategy to arrest the cervical resorption process and to prevent further resorption without changing pulpal vitality and successful seal of invasive cervical resorption defect using MTA with a sandwich technique.     

Absence of apical resorption during orthodontic treatment on a tooth with a complicated crown fracture and root canal treatment: a case report

Root resorption often occurs after tooth trauma and may also occur during orthodontic tooth movement. This has been attributed to bacteria and inflammation or a combination of both aetiologies. The literature suggests that root canal treatment performed on a traumatized tooth that will concurrently or subsequently undergo orthodontic tooth movement may forestall the resorptive process. This case report provides evidence for this prevention and discusses the hypothesis for the absence of resorption on root-treated teeth.     

Effect of orthodontic force on periodontal tissue metabolism a histologic and biochemical study in normal and hypocalcemic young rats

The relationship between force and degradation activity after application of orthodontic force is still obscure. Of particular clinical interest are the etiologic factors behind excessive root resorptions appearing in connection with orthodontic movement of teeth that has been proposed to be influenced by systemic factors regulating the tissue-degrading activity in periodontal tissues. Thus, the aim was, by histologic and new biochemical methods, to investigate the effect of orthodontic forces on the periodontal tissues in the normal and the hypocalcemic situation with secondary hyperparathyroidism. Root resorptions were induced in upper incisors of normal and hypocalcemic rats by subjecting the teeth to a moderate orthodontic force. In both groups the resorption of the roots occurred consistently in the vicinity of reorganizing areas of the periodontal ligament (PDL) with ongoing degradative activities and alveolar bone resorption. Furthermore, specific cell metabolic changes in alveolar bone and PDL in tension and pressure zones were detected and quantified by biochemical determination of alkaline phosphatase activity. This biochemical quantification of the metabolic changes together with the morphologic observations gave the clinically valuable information that the observed increase in occurrence and severity of root resorptions in moderate hypocalcemia was related to an increase in alveolar bone turnover. This study has shown that root resorptions were clearly related to the degradation process occurring in the vicinity of the hyaline zone and that in the hypocalcemic situation, the increase in root resorptions was related to an enhanced alveolar bone resorption. Thus, factors that minimize the time for resorptive/degradative activity should be discussed in this context rather than force per se.     

Invasive Cervical Resorption Following Trauma

Invasive cervical resorption is an insidious and often aggressively destructive form of external root resorption which may occur as a late complication following dental trauma particularly where it involves damage to cementum and supporting tissues. While this resorption may be evident clinically as a pink coronal discolouration, later with cavitation of the enamel, often there are no obvious external signs and the condition is only detected radiographically. It is characterised by the invasion of the cervical region of the root by fibrovascular tissue which progressively resorbs dentine, enamel and cementum. The dental pulp remains protected by an intact layer of dentine and predentine until late in die process. Ectopic calcifications can be observed in advanced lesions both within the invading fibrous tissue and deposited directly onto the resorbed dentine surface. The aetiology of invasive cervical resorption is unknown but trauma has been documented as a potential predisposing factor. A recent study by the author of 222 patients with a total of 257 teeth which displayed varying degrees of invasive cervical resorption showed that trauma alone was a potential predisposing sole factor in 14% of patients and 15.1% of teeth. Trauma in combination with bleaching, orthodontics or delayed eruption was found in an additional 11.2% of patients or 10.6% of teeth and of these a combination of trauma and bleaching occurred in a relatively high proportion of 7.7% of patients or 7.4% of teeth. This study also revealed that of other potential predisposing factors orthodontics was the most common sole factor constituting 21.2% of patients and 24.1% of teeth examined. Successful treatment of invasive cervical resorption is dependent on the extent of the resorptive process. Teeth with invasive cervical resorption have been divided into four classes. Whilst several treatment modalities are possible, a clinical evaluation of the treatment of this condition by the topical application of a 90% aqueous solution of trichloracetic acid, curettage, endodontic therapy where necessary and restoration with a glass ionomer cement has been evaluated on 94 patients with a total of 101 teeth with a minimum follow-up period of three years. Results indicate a satisfactory treatment outcome can be anticipated in Class 1, 2 and 3 cases. In Class 4 resorption no treatment or alternative therapy is recommended. Diagnosis of lesions at an early stage of development is highly desirable and therefore the patients who have a potential for the development of this condition by virtue of a history such as trauma should be monitored radiographically at intervals throughout life.     

The role of endodontics in the treatment of luxated permanent teeth

Abstract  – Pulp necrosis is a common complication following traumatic dental injuries and is related to the type and severity of the injury, as well as to the stage of development of the injured tooth. Endodontic intervention is required when there are clinical and radiographic signs of pulpal infection and its sequelae. Arrested tooth development with periradicular pathosis, external inflammatory root resorption, sinus tract formation and pain on percussion are indicative of root-canal infection in the post-traumatized teeth, and require immediate endodontic treatment. The use of calcium hydroxide in the treatment of teeth with post-traumatic pulp necrosis and its sequelae has been shown to be extremely beneficial for the long-term retention of the injured teeth. Calcium hydroxide has been shown to arrest and repair external inflammatory root resorptive defects, eliminate the endodontopathic microorganisms from the root canal system and induce hard-tissue barrier formation at the apex of non-vital immature teeth. This paper reviews the endodontic treatment required by post-traumatic non-vital permanent teeth.