CASE REPORTCASE REPORTCASE REPORTCASE REPORT

68 ARCHIVES OF DENTAL AND MEDICAL RESEARCH

Treatment of Internal Root Resorption iCase Report Sanju Patel1, Dipti ChoksiGhanshyam Patel1

1Post graduate student, Department of Conservative Dentistry & Endodontics, Faculty of Dental ScienceNadiad; 2Professor and Head, Department of Conservative Dentistry & Endodontics, Faculty of Dental ScienceNadiad; 3Professor, Department of Conservative Dentistry & En4Senior lecturer, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science Address for Correspondence: Dr. Sanju Patel, Department of Conservative Dentistry & EndodonIndia. ABSTRACT: A clinician encounters a variety of pulpodefinition it is a condition associated with either a physiologic or a pathologic process of dentin, cementum or bone. Internal as well as external resorption signifies a very complex pathological interaction of the cells of pulp, periradicular and periodontal tissues. An insidious process that is generally found in teeth withrelated pulpits, traumatic injuries, and iatrogenic causes. Generally a tooth with internal root resorption is asymptomatic and this condition is diagnosed on routine radiographic examination. Accurate diagnosis and immediate institution of treatment in this condition is important to improve the prognosis of such teeth. This case report having resorptive defect in the middle 1/3rd of maxillary left lateral incisor which was treated non-surgically with endodontic treatment. The step back technique for biopreparation was used and obturation was carried out with hybrid technique where apical 1/3rd till resorptive defect was obturated and the defect was backfilled with thermoplastized guttapermonth follow up demonstrated clinically asymptomatic and adequately functional tooth, with radiographic signs of healing. Keywords: Gutta-Percha, Resorption Lacunae, Thermoplastized

INTRODUCTION Internal root resorption is a usually asymptomatic, slowly progressing, and detectable upon routine radiographic examination.1 An oval enlargement of the root canal space in radiograph is seen in affected tooth. The resorption lacuna, a continuation of the distorted outer borders of the root canal is confirmed by different angulations techniques of radiographs.2 A deviation from the standard procedure is required for diagnosis and management of internal resorption. The key to success in arresting the process of internal resorption is total removal of pulp horn. The cause of internal resorption is not fully understood.3 Suggested contributing factors are trauma, persistent chronic pulpitis as well as

ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 3 Issue 1

Treatment of Internal Root Resorption in Maxillary Lateral Incisor: A

Dipti Choksi2, Barkha Idnani3, Nirav Parmar4,

student, Department of Conservative Dentistry & Endodontics, Faculty of Dental ScienceProfessor and Head, Department of Conservative Dentistry & Endodontics, Faculty of Dental ScienceProfessor, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science

Senior lecturer, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science

Department of Conservative Dentistry & Endodontics, Faculty of Dental Science,

A clinician encounters a variety of pulpo-pathologic conditions. Resoprtion is one such condition. By definition it is a condition associated with either a physiologic or a pathologic process of dentin, cementum or bone. Internal as well as external resorption signifies a very complex pathological interaction of the cells of pulp, periradicular and periodontal tissues. An insidious process that is generally found in teeth with a long standing chronic inflammation of the pulp, caries related pulpits, traumatic injuries, and iatrogenic causes. Generally a tooth with internal root resorption is asymptomatic and this condition is diagnosed on routine radiographic examination.

ate diagnosis and immediate institution of treatment in this condition is important to improve

This case report having resorptive defect in the middle 1/3rd of maxillary left lateral incisor which h endodontic treatment. The step back technique for bio

preparation was used and obturation was carried out with hybrid technique where apical 1/3rd till resorptive defect was obturated and the defect was backfilled with thermoplastized guttapermonth follow up demonstrated clinically asymptomatic and adequately functional tooth, with

Resorption Lacunae, Thermoplastized.

Internal root resorption is a rare finding, usually asymptomatic, slowly progressing, and detectable upon routine radiographic

An oval enlargement of the root canal space in radiograph is seen in affected tooth. The resorption lacuna, a continuation of

borders of the root canal is confirmed by different angulations techniques

A deviation from the standard procedure is required for diagnosis and management of internal resorption. The key to success in arresting the process of internal

sorption is total removal of pulp horn. The cause of internal resorption is not fully

Suggested contributing factors are trauma, persistent chronic pulpitis as well as

orthodontic treatment.4

because the tooth is asymptomaticChronic inflammatory process in the pulp tissue combined with the loss of the protective layer of odontoblasts and predentin is assumedto cause dentinal resorption. multinucleated giant cells that are adjacent to the granulation tissue in the resorb internal aspect of root canal.which the resorptive process reaches the cervical area of the crown may have a pinkish color, known as ‘pink tooth’ resulting from granulation tissue ingrowths.Radicular portion it often goes it has perforated the external surface. Stage at which the process is detected & treated affects the prognosis. Extirpation of entire pulpal tissue is the main motive of its treatment. The

AODMR

n Maxillary Lateral Incisor: A

, Ajaz Goplani1,

student, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science-Professor and Head, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science-

dodontics, Faculty of Dental Science-Nadiad, Senior lecturer, Department of Conservative Dentistry & Endodontics, Faculty of Dental Science-Nadiad

tics, Faculty of Dental Science, Nadiad,

pathologic conditions. Resoprtion is one such condition. By definition it is a condition associated with either a physiologic or a pathologic process resulting in loss of dentin, cementum or bone. Internal as well as external resorption signifies a very complex pathological interaction of the cells of pulp, periradicular and periodontal tissues. An insidious

a long standing chronic inflammation of the pulp, caries related pulpits, traumatic injuries, and iatrogenic causes. Generally a tooth with internal root resorption is asymptomatic and this condition is diagnosed on routine radiographic examination.

ate diagnosis and immediate institution of treatment in this condition is important to improve

This case report having resorptive defect in the middle 1/3rd of maxillary left lateral incisor which h endodontic treatment. The step back technique for bio-mechanical

preparation was used and obturation was carried out with hybrid technique where apical 1/3rd till resorptive defect was obturated and the defect was backfilled with thermoplastized guttapercha. A six-month follow up demonstrated clinically asymptomatic and adequately functional tooth, with

Late diagnosis is because the tooth is asymptomatic. Chronic inflammatory process in the pulp tissue combined with the loss of the protective layer of odontoblasts and predentin is assumed to cause dentinal resorption. Activated multinucleated giant cells that are adjacent to the granulation tissue in the inflamed pulp resorb internal aspect of root canal.5 Teeth in which the resorptive process reaches the cervical area of the crown may have a pinkish color, known as ‘pink tooth’ resulting from granulation tissue ingrowths.6 Radicular portion it often goes unnoticed until it has perforated the external surface. Stage at which the process is detected & treated affects

Extirpation of entire pulpal tissue is the main motive of its treatment. The

Patel et al: Treatment of Internal Root Resorption in

69 ARCHIVES OF DENTAL AND MEDICAL RESEARCH

presented case elicits the challenges encountered in diagnosing, treatment planning, cleaning shaping and achieving a three dimensional obturation.3,7 CASE PRESENTATION A 50 year old female patient came tothe Department of Conservative Dentistry and Endodontics, with a chief complaint of food lodgment in upper left front teeth since 3 months. The patient had no significant medical history. Patient had past dental history of endodontically treated tooth maxillary left canine before 3 months. Intra oral examination revealed caries in maxillary left lateral incisor.Vitality Test was performed in relation with 22, which showed no response.periapical (IOPA) Radiographic interpretation revealed the presence of an oval shaped radiolucency at the junction of coronal & middle one third of the root in 22 whsuggestive of internal resorptiondiagnosis of pulp necrosis with internal root resorption was made.

Figure 1: Pre-operative IOPA radiograph with different angles shows ballooning within the root canal

In first appointment rubber dam was placed and access cavity was prepared in 22.canals were completely negotiated, working length IOPA was taken (Figure mechanical preparation was done with hand Kfiles using step back technique and EDTA was used as a lubricant to remove the necrotic debris. In between the instrumentation, the canal was irrigated with 3% sodium hypochlorite and saline. The apical the canal was enlarged to no. 60 KUltrasonic agitation with 3% sodium hypochlorite was done to clean the lacunae

Treatment of Internal Root Resorption in Maxillary Lateral Incisor

ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 3 Issue 1

presented case elicits the challenges n diagnosing, treatment planning,

cleaning shaping and achieving a three

A 50 year old female patient came tothe Department of Conservative Dentistry and Endodontics, with a chief complaint of food

upper left front teeth since 3 months. The patient had no significant medical

Patient had past dental history of endodontically treated tooth maxillary left

Intra oral examination revealed caries in maxillary left lateral ncisor.Vitality Test was performed in relation

with 22, which showed no response.Intraoral periapical (IOPA) Radiographic interpretation revealed the presence of an oval shaped radiolucency at the junction of coronal & middle one third of the root in 22 which was suggestive of internal resorption (Figure 1). A diagnosis of pulp necrosis with internal root

with different angles

shows ballooning within the root canal

dam was placed and access cavity was prepared in 22. The canals were completely negotiated, working

(Figure 2). The bio-mechanical preparation was done with hand K- files using step back technique and EDTA was used as a lubricant to remove the necrotic

In between the instrumentation, the canal was irrigated with 3% sodium

The apical portion of the canal was enlarged to no. 60 K- file. Ultrasonic agitation with 3% sodium hypochlorite was done to clean the lacunae

area. Canal was dried with sterile paper points. The access cavity was sealed with Cavit.

Figure 2: Working length IOPA ra

In the next appointment, evaluation of upper left lateral incisor was done and the tooth was found to be asymptomatic.dried with sterile paper points.control to assess the good fit of the master guttapercha cone was carried out.Final irrigation with 3% sodium hypochlorite and saline was done, root canal was dried with sterile paper tips followed by application ofAH Plus sealer (DentsplyBaillaigues, Switzerlandlentulospiral. Obturation of the apical third of the root with guttapercha was done with help of finger and hand plugger, till resorptive defect. Thermo plasticized injectable guttapurcha (ULTRAFIL®3D Whaledent) backfilled technique was used in the resorption lacunae to completely fill the wide canal space (Figure 3).was sealed with Cavit.

Figure 3: Sealing of the resorptive defect using thermoplasticized technique

Patient was recalled for post endodontic restoration in maxillary left lateral incisor.the last appointment post endodontic restoration was done with composite resin restoration (Figure 4). Patient was kept on follow up for 6 months to check the prognosof treatment. After 6 months IOPA showed

y Lateral Incisor

area. Canal was dried with sterile paper points. The access cavity was sealed with Cavit.

Figure 2: Working length IOPA radiograph

In the next appointment, evaluation of upper left lateral incisor was done and the tooth was found to be asymptomatic. The canal was dried with sterile paper points. Radiographic control to assess the good fit of the master guttapercha cone was carried out.Final

3% sodium hypochlorite and root canal was dried with

sterile paper tips followed by application of Dentsply Maillefer,

Baillaigues, Switzerland) with help of Obturation of the apical third of

the root with guttapercha was done with help of finger and hand plugger, till resorptive defect. Thermo plasticized injectable gutta-

Hygenic, Coltène, ) backfilled technique was used in

the resorption lacunae to completely fill the 3). The access cavity

Figure 3: Sealing of the resorptive defect using

thermoplasticized technique

Patient was recalled for post endodontic restoration in maxillary left lateral incisor.At the last appointment post endodontic restoration was done with composite resin

Patient was kept on follow up for 6 months to check the prognosis of treatment. After 6 months IOPA showed

Patel et al: Treatment of Internal Root Resorption in

70 ARCHIVES OF DENTAL AND MEDICAL RESEARCH

good prognosis of treatment and the patient was asymptomatic.

Figure 4: After treatment IOPA

Figure 5: 6 month follows up

DISCUSSION A pathologic process initiated within the pulp space with loss of dentin is defined as internal resorption.8 The diagnosis is oftenrather than intentional as the process isasymptomatic until perforation occurs. The etiology of internal resorption is not fully understood. Risk factors considered are trauma and chronic pulpitis.7 Gabor their study had found internal resorption to be a frequent finding in teeth with pulp inflammation or necrosis. None of the samples in their study with healthy pulps revealed any sign of internal resorption.9 The etiology in this case was attributed to dental caries, which resulted in internal resorption followed by pulp necrosis. An active internal resorptive process can not be ruled by a negative sensitivity test as the coronal portion of the pulp may be necrotic whereas the apical pulp which includes the resorptive defect may remain vital. If the pulp becomes necrotic after a period of active resorption it shall give a negative sensitivity result, radiographic signs of internal resorption& apical breakdown.

Treatment of Internal Root Resorption in Maxillary Lateral Incisor

ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 3 Issue 1

good prognosis of treatment and the patient

Figure 4: After treatment IOPA

Figure 5: 6 month follows up

pathologic process initiated within the pulp is defined as internal

The diagnosis is often accidental rather than intentional as the process is asymptomatic until perforation occurs. The

of internal resorption is not fully understood. Risk factors considered are

Gabor et al in internal resorption to be

a frequent finding in teeth with pulp inflammation or necrosis. None of the samples in their study with healthy pulps revealed any

in this case was attributed to dental caries, which resulted in internal resorption followed by pulp necrosis. An

process can not be ruled by a negative sensitivity test as the coronal portion of the pulp may be necrotic

the apical pulp which includes the resorptive defect may remain vital. If the pulp becomes necrotic after a period of active resorption it shall give a negative sensitivity result, radiographic signs of internal

breakdown.10 As all the

above features were observedin the present case a diagnosis of pulp necrosis was made.A radiograph can never be a sole diagnostic tool. The diagnosis of internal resorption should be confirmed throughout the treatment.10 Any bleeding from the canal should be ceased by expiration of pulp. Perforation can be suspected by clinician if any bleeding is present in second visit. Perforationin the present case can be ruled out by absences of bleeding in both the appointments. For thorough removal of necrotic debristhe irregular canal space ultrasonic irrigation was used.11 Rodig et al have shown ultrasonic irrigation to be more effective than syringe irrigation in removal of debris from extensions in straight root canals.12

injectable gutta-percha with backfilled obturation technique was preferred over lateral condensationas the former produces movement of gutta-percha, filling irregularities & accessory canals.13 Cone beam computed tomography (CBCT) can be used for diagnosis &complex cases of suspected perforative defects. Bhuva et al have shown that CBCThas a superior diagnostic ability & also resulted in an increased likelihood of correct management of internal resorptive lesions.Thus modifications can be made to treatment procedures in view of additional information obtained from CBCT. Lastly if internal resorptive cavities isexcessively large. It increases the probability of root fractures during functional loading. A light transmitting post is used to manage such cases.8 The defect in the presented case was not extensive & showedthickness on radiographic examination so root reinforcement was not needed. CONCLUSION Early detection, appropriate treatment planning, removal of inflammatory pulp tissue & three dimensional obturation are the factors affecting the success of management of internal root resorption.

y Lateral Incisor

bove features were observedin the present case a diagnosis of pulp necrosis was made. A radiograph can never be a sole diagnostic tool. The diagnosis of internal resorption should be confirmed throughout the

Any bleeding from the canal be ceased by expiration of pulp.

Perforation can be suspected by clinician if any bleeding is present in second visit. Perforationin the present case can be ruled out by absences of bleeding in both the

For thorough removal of necrotic debris from the irregular canal space ultrasonic irrigation

Rodig et al have shown ultrasonic irrigation to be more effective than syringe irrigation in removal of debris from extensions

12 A thermoplastic rcha with backfilled

obturation technique was preferred over lateral condensationas the former produces movement

filling irregularities &

tomography (CBCT) can be used for diagnosis & management in

mplex cases of suspected perforative defects. Bhuva et al have shown that CBCT has a superior diagnostic ability & also

an increased likelihood of correct internal resorptive lesions.14

can be made to treatment additional information

Lastly if internal resorptive cavities is excessively large. It increases the probability

fractures during functional loading. A light transmitting post is used to manage such

The defect in the presented case was not extensive & showed adequate dentin thickness on radiographic examination so root reinforcement was not needed.

Early detection, appropriate treatment planning, removal of inflammatory pulp tissue

three dimensional obturation are the factors affecting the success of management of

Patel et al: Treatment of Internal Root Resorption in Maxillary Lateral Incisor

71 ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 3 Issue 1

REFERENCES 1.Andreasen FM, Andrasen JO. Textbook and color atlas of traumatic injuries to the teeth, 3rd edn. St. Louis, MO: Mosby; 1994. p. 563. 2.Trope M, Chivian N. Root resorption. In: Cohen ST, Burns R, editors. Pathways of the pulp, 6th edn. St. Louis, MO: Mosby; 1994. p. 486–512. 3.Singh S, Kulkarni G. Resorptions Revisited - Internal Resorption: Two Case Reports. Endodontology 2013;25(1):129-34. 4.Weine FS. Endodontic therapy, 4th edn. St. Louis, MO: Mosby; 1989. p. 150. 5.Tronstad L. Root reorption-etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988;4:241-52. 6.Mummery JH. The pathology of pink spots on teeth. Br Dent J 1920;41:301-11. 7.Keinan D, Heling I, Stabholtz A, Moshonov J. Rapidly progressive internal root resorption: A case report. Dent Traumatol 2008; 24(5):546-9. 8.Hariharan VS, Nandlal B, Srilatha KT. Management of recurrent fracture of central incisor with internal resorption using light transmitting (luminex) post. J Indian Soc Pedod Prev Dent 2010;28(4):288-92. 9.Gabor C, Tam E, Shen Y, Haapasalo M. Prevalence of internal inflammatory root resorption. J Endod 2012;38(1):24-7. 10.Cohen S, Chapter 17, The Role of Endodontics after Dental Traumatic Injuries. Hargreaves KM, Cohen S, Berman LH, Cohen’s Pathways of the Pulp, 10th edition, Mosby Elsevier 2011. 11.Weller RM, Brady JM, Bernier WE. Efficacy of ultrasonic cleaning. J Endod 1980;6(9):740-3. 12.Rodig T, Segdhi M, Konietschke F, Lange K, Zeibolz D, Hulsmann M. Efficacy of syringe irrigation, RinsEndo and passive ultrasonic irrigation in removing debris from irregularities in root canals with different apical sizes. Int Endod J 2010;43(7):581-9. 13.Wu MK, Kastakova A, Wesselink PR. Quality of cold and warm gutta-percha fillings in oval canals in mandibular premolars. Int Endod J 2001;34:485.

14.Bhuva B, Barnes JJ, Patel S. The use of limited cone beam computed tomography in the diagnosis & management of perforating internal resorption. Int Endod J 2011;44(8):777-86.

How to cite this article: Patel S, Choksi D, Idnani B, Parmar N, Goplani A, Patel G. Treatment of Internal Root Resorption in Maxillary Lateral Incisor: A Case Report. Arch of Dent and Med Res 2017;3(1):68-71.