Invasive cervical resorption pdf

The final aim of the management strategy is to ensure that the tooth diagnosed with ECR is maintained in a healthy and functional status on the dental arch, avoiding tooth extraction, and to improve aesthetics when indicated. In order to maintain the affected tooth on the dental arch, in a healthy and functional status, it is necessary to proper restore the tooth, by excavating the resorptive tissue, closing of the subsequent defect and portals of entry in order to arrest the resorptive process 9.

Performing a preoperative CBCT helps identify the true nature of the resorption, providing valuable information that can help establish a correct treatment plan 9 , 18 , 35 , In some of the cases, when the lesion has perforated the root canal walls or this may happen during the excavation of the resorptive process, endodontic treatment might be required as well 16 , 46 , External approach can be combined with surgical treatment, such as flap surgery, when the lesions are extended far apically than the gingival margin.

Small lesions, with inaccessible entry points which may extend apicocoronally and circumferentially around the root canal space, can be treated only using an internal approach, defined by the endodontic treatment and the restoration of the lesion 7 , External repair of smaller resorptive processes, such as Heithersay class 1 and 2 or 3D Patel classes 1Ad, 2Ad, 2Bd, is thought to have a positive outcome; in these cases, the root canal is typically intact and the pulpal tissue is healthy, without any symptoms of reversible or irreversible pulpitis 18 , The external non-surgical approach can be performed on ECR teeth on which the lesions are located above the coronal third of the root, whereas the ECR lesions located below the gingival margin can benefit from surgical repair, including an intra-crevicular incision or muco-periosteal flap surgery 47 , The application of TCA is used in order to stimulate coagulation necrosis of the lesion and tissue located in an accessible channel of ECR The TCA further penetrates the more inaccessible resorptive channels, which may not be visible and opened for excavation by mechanical instruments 38 , In order to protect the neighboring tissues, the rubber dam isolation system can be applied to the causal tooth.

The TCA manipulation technique involves soaking a cotton pellet or micro-brush in the solution, then removing the excess and applying it in direct contact with the granulomatous tissue of the resorptive process for about min, until coagulation necrosis occurs 47 , The technique is very sensitive, and it necessitates the use of magnification, such as surgical microscope or loups, for the excavation of the granulomatous tissue with the help of hand instruments excavators ; the use of burs should be reduced to the maximum, in order to protect the intact remaining tooth structure Small internal resorptive lesions can be accessed by using ultrasonic instruments under magnification without any risk of removing unnecessary sound dentine and can securely debride the lesions without damaging the periodontal tissues The use of magnification helps to differentiate between healthy dentine and reparative hard tissues, and to remove as much as possible from the resorptive tissue.

Being unable to completely remove the resorptive tissue, the lesions can recur 1. Moreover, they help with the formation of reparative dentine, cement and encourage the differentiation of odontoblasts 55 , Although GI and RMGI have certain advantages such as biocompatibility, fluoride release and chemical adhesion to dentine, they do not ensure bone and cement regeneration These bioactive restorative materials have the ability to regenerate the cement, the PDL and the bone around them 50 , As a technique, it is recommended to initially identify, negotiate and shape the root canal, and then to block the canal space using a suitable gutta-percha cone in order to maintain it patent during the restoration of the ECR lesion.

After complete restoration of the defect as described above , endodontic treatment may be completed. In this way, the risk of blocking the root canal is limited As an alternative to surgical approach, orthodontic extrusion can be performed in order to access the ECR lesions located far below the gingival margin When the ECR lesion has perforated or is close to perforate the root canal, and an external repair is not a viable solution, as there is no optimal access, the treatment option is an internal approach.

The internal repair technique requires endodontic treatment and subsequent restoration of the ECR cavity When small entry points are located apically from the epithelial attachment, an internal repair is recommended. An internal repair, meaning endodontic treatment as a first step, can assess teeth with minor communications between the root canal space and the resorptive lesion.

In order to decontaminate the endodontic system, sodium hypochlorite can be used as the main irrigant. Moreover, sodium hypochlorite can dissolve the granulomatous tissue and can achieve hemostasis. Then, a calcium hydroxide paste, which has an alkaline pH, may be placed in the root canal to stimulate the coagulation necrosis and to inhibit the osteoclastic action, whereas the osteoblastic one occurs 64 , For the protection of the PDL, a polytetrafluoroethylene tape may be compacted between the tooth and the adjacent tissues.

Endodontic treatment may then be finalized. After the removal of granulomatous tissue through the access cavity and the root canals, the defects were repaired with MTA or Biodentine Applying bioactive materials on the ECR cavities will result in an alkaline pH that may impede the osteoclastic function of any remaining ECR tissues, reducing the risk of recurrence External cervical resorption ECR still remains a relatively uncommon pathology which leads to the loss of hard dental tissues due to osteoclastic activity.

Its multifactorial etiology being poorly understood, more research is needed to establish the cause-and-effect relationship of all the etiological factors. The improved radiographic detection using the cone-beam computed tomography CBCT allows a precise diagnosis, a more accurate classification of the lesion and leads to a more predictable treatment plan for the benefit of the patients.

STN performed the radiological analysis and prepared the images. LCR carefully revised and reviewed the paper in light of the literature data. All authors read and approved the final version of the manuscript for publication. National Center for Biotechnology Information , U. Journal List Exp Ther Med v. Exp Ther Med. Published online Jul Author information Article notes Copyright and License information Disclaimer. Received May 31; Accepted Jun This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License , which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Associated Data Data Availability Statement The authors confirm that all the information provided in this review is documented by relevant references. Abstract External cervical resorption ECR is a relatively unknown and insidious pathology characterized by the loss of hard dental tissues such as: Enamel, cementum and dentine due to clastic function.

Keywords: external cervical resorption, cone beam computed tomography, dentinal penetration, circumferential spread, external approach, internal approach. Introduction Dental resorption is considered to be a challenge to dentistry due to its complexity.

Pathogenesis and etiology ECR is a dynamic and complex process. Histology ECR is a complex and dynamic process. Classification Heithersay developed the first classification of ECR in Open in a separate window.

Figure 1. Figure 2. Clinical and radiographic presentation Clinically, there is no classic presentation or particular symptomatology for ECR.

Treatment The final aim of the management strategy is to ensure that the tooth diagnosed with ECR is maintained in a healthy and functional status on the dental arch, avoiding tooth extraction, and to improve aesthetics when indicated.

External approach External repair of smaller resorptive processes, such as Heithersay class 1 and 2 or 3D Patel classes 1Ad, 2Ad, 2Bd, is thought to have a positive outcome; in these cases, the root canal is typically intact and the pulpal tissue is healthy, without any symptoms of reversible or irreversible pulpitis 18 , Internal approach When the ECR lesion has perforated or is close to perforate the root canal, and an external repair is not a viable solution, as there is no optimal access, the treatment option is an internal approach.

Conclusions External cervical resorption ECR still remains a relatively uncommon pathology which leads to the loss of hard dental tissues due to osteoclastic activity. Acknowledgements Not applicable. Funding Statement Funding: No funding was received. Availability of data and materials The authors confirm that all the information provided in this review is documented by relevant references. Ethics approval and consent to participate Not applicable. Patient consent for publication The patient provided consent for publication.

Competing interests The authors declare that they have no competing interests. References 1. External cervical resorption: A review. J Endod. External cervical resorption-part 1: Histopathology, distribution and presentation. Int Endod J. Patel S, Ford TP. Is the resorption external or internal?

Dent Update. Patel S, Saberi N. The ins and outs of root resorption. Br Dent J. Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption.

Trauma could be one of the predisposing factors for ICR. According to Heitherssay, After trauma generally the incidents which can be contributory to ICR development are bleaching due to non-vitality, orthodontic treatment, forcible repositions after trauma, trauma to cementoenamel junction region due to interdental wiring.

Various reports have shown that the intracoronal bleaching results in ICR. Several mechanisms given for this are- hydrogen peroxide leaking through dentinal tubule on to external tooth surface which might denature dentin and provoke immunological response. Any surgical procedure that result in defect or damage to cementoenamel junction region can be a predisposing factor for ICR.

The exact association is uncertain but heat damage to bone, impairment of blood supply are important factors associated with root resorption. According to Heitherssay periodontal surgeries which might result in damage to cementum can result in resorption in 1. Usually, the resorption is prevented after periodontal debridement as the contact of connective tissue cells with the root surface is prevented which also prevents inflammatory process.

The increased migration of connective tissue fibroblasts can enhance the risk of resorption. Other miscellaneous factors are developmental defects like hypoplasia or hypomineralization of cementum, bruxism. Various systemic factors have also been reported to be associated with ICR though the association is still not confirmed. Moskow et al reported a case of ICR in patient with hyperoxaluria and oxalosis.

Increased concentration of oxalates caused by kidney failure results in precipitation of crystals in pulp, bone marrow, gingival connective tissue, periodontal ligament. These crystalline deposits provoked a granulomatous foreign body reaction which might have resulted in aggressive ICR. Hence the close relatives should be examined for the similar lesions for early diagnosis and treatment. The periodontal tissues are sensitive to hormonal fluctuations during puberty and pregnancy but still there is no clear evidence of role of hormonal changes in pathogenesis of ICR.

This virus is associated with the felin odontoclastic resorptive lesions in domestic cats. They have advised future studies to find out the exact and possible role of feline virus in mICR. He reported cases with idiopathic ICR running regionally. In these patients anamnestic information revealed severe viral diseases during childhood. This neuronal virus spreading along the nerve paths could be possible explanation for the unexpected resorptions.

The extent of resorption process in the dentition followed the virus infected nerve paths and resorption process stopped reaching regions that were innervated differently and not infected by virus. So it is not possible to find out the exact etiology of ICR rather it is considered as multifactorial resulting from variety of predisposing factors which ultimately leads to an aggressive lesion of ICR.

Heithersay G. Table 1 has proposed a clinical classification of invasive cervical resorption depending on the amount of destruction. The extent of resorptive process dictates the clinical manifestations of the lesion.

Clinically the lesion can be asymptomatic and could be an incidental finding on routine dental radiographic examination. The lesion poses diagnostic difficulties as it may be insidious in onset without any visual signs and symptoms. Clinically, the lesion may present as painless pinkish discoloration of the crown indicating resorptive process.

The reason for this is that the resorption starts on the root surface, but when the predentin is reached, it proceeds laterally and in an apical and coronal direction, progressively enveloping the root canal.

Probing the cavity results in bleeding and gives spongy texture of granulomatous tissue. At times, the resorption cavity can also give feeling of hard, mineralized tissue. Carious lesions are softer due to disintegration of organic component of dentin. If the lesion is long standing, then mottled appearance may be seen due to deposition of calcified reparative tissue within areas of cavity surface.

If the lesion is internal resorption the radiolucency will remain static; if lesion is ICR then the lesion will move according to Clarks rule or SLOB rule. If resorptive process extends in radicular dentin it forms canals containing resorptive tissue which have connections further apically with periodontal ligament. Microscopically this lesion is similar to any other inflammatory root resorption. The resorptive cavity contains granulomatous fibrovascular tissue.

It consists of mass of fibrous tissue, inflammatory cell infiltrate consisting of lymphocytes, plasma cells, histiocytes, macrophages, numerous blood vessels and clastic resorbing cells adjacent to the dentin surface.

A thin layer of dentin and predentin is always present separating inflammation free pulp tissue. The resorbing tissue is also free of acute inflammatory cells which rules out the possibility of infection as a primary etiology.

In advanced lesions ectopic calcification can also be observed within the invading fibrous tissue and on the surface of resorbed dentin. The Incisive cervical root resorption begin and progress asymptomatically. When multiple teeth are involved resorption may not occur simultaneously or progress at same rate.

Separate lesions can begin at different time. The basic treatment modalities are directed towards the complete removal of resorptive tissue with spoon shaped excavator or with bur at slow speed. Once sound dentinal margins are achieved dentinal walls are conditioned by some chelating agent to destroy remnants of resorptive tissue.

Brazil Fig. Fifteen days after the insertion of the calcium hydroxide dressing. The root-filling was then cut at the middle third with a heated plugger. Switzerland was prepared following the manufacturer's instructions and placed with a small amalgam carrier and firmly condensed with the same plugger used to cut the root-filling Fig. MTA was not placed above the cervical region to avoid possible tooth discolouration.

The pulp chamber above the MTA was then filled with glass ionomer cement and restored with light-curedcomposite resin. The patient was warned of the long-term risks of root fracture in the event of post and crown placement.

After the last session. Clinical examination at two years revealed no periodontal problems on probing of the gingival sulcus on both buccal and palatal aspects, as well as no changes in tooth colour Fig. In some cases. The term 'invasive cervical resorption' suggests that resorption should occur at the cervical area of the tooth this is not always the case because of the location of periodontal insertion. The main reason for the divergent diag- noses in this case was the location of the communication with the periodontium between the cervical and middle root thirds.

The diagnosis of ICR was determined after thorough clinical and radio- graphic examination of the case, which revealed signs such as irregular radiolucency. There was no tooth discolouration thanks to the controlled level of application of MTA; however, the new version of this product. White MTA. The possibility of overflow of MTA and the absence of a post might constitute a contraindicationof this product in this case.

This possibility was discounted since it would be possible to surgically remove any overflow material. The application and placement of MTA for non-surgical treat- ment might be more difficult to perform because of the level of the resorption.

However, when conducted by a competent clinician, the placement of MTA may be a good non-surgical option, provided it is carefully placed and condensed on the resorption area. This approach not only increases the chances of treatment success, but also maintains the possibility of performing surgical treatment later figure 6: Clinical aspect of the anterior teeth after two years if necessary.

Endodontics: Biological and According to Heithenay 8. Sao Paulo, Brazil: Artes Medicas cervical resorption varies depending on the extent of the resorption - dental division; Cohen S. Burns RC. Pathways of the pulp, 7th ed. Radiographic features of lesions vary from well-delineated to irregularly bordered mottled radiolucencies, and these can be confused with dental caries.

A characteristic radiopaque line generally separates the image of the lesion from that of the root canal, because the pulp remains protected by a thin layer of predentin until late in the process.

Histopathologically, the lesions contain fibrovascular tissue with resorbing clastic cells adjacent to the dentin surface.