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| CASE REPORT |
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| Year : 2020 | Volume
: 7
| Issue : 2 | Page : 64-66 |
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Surgical management of class 3 invasive cervical resorption
Zehra Shavez, Shaikh Shahbaz, Sharique Alam
Department of Conservative Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| Date of Submission | 31-May-2019 |
| Date of Acceptance | 06-Feb-2020 |
| Date of Web Publication | 20-Jun-2020 |
Correspondence Address:
Zehra Shavez
Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdrr.jdrr_10_20
Invasive cervical resorption (ICR) is a pathologic loss of dental hard tissue at the cervical region of tooth beneath the epithelial attachment. ICR is multifactorial in origin and has various predisposing factors such as orthodontic treatment, trauma, and internal bleaching. Thus, a multidisciplinary approach comprising of surgical repair with root canal treatment is required for its successful treatment outcome.
Keywords: Cervical region, invasive cervical resorption, surgical management
How to cite this article:
Shavez Z, Shahbaz S, Alam S. Surgical management of class 3 invasive cervical resorption. J Dent Res Rev 2020;7:64-6 |
| Introduction | |  |
Invasive cervical resorption (ICR) is a pathologic process resulting in loss of dental hard tissue.[1] It is usually located beneath the epithelial attachment of the tooth at the cervical region.[2] The management of ICR presents a dilemma to the clinician. Thus, a multidisciplinary approach is required for the successful management of the lesion. Etiology and pathogenesis of ICR is still not well understood; however, a defect in the cementoblast layer coupled with disruption of RANK-RANKL system is considered essential for the lesion to occur.[3] Potential predisposing factors include orthodontic treatment, trauma, internal bleaching, surgery, and restorative treatment.[4] ICR is multifactorial in origin, and a combination of predisposing factors was identified in majority of clinical cases.[5] The maxillary central incisor is the most commonly affected tooth, followed by maxillary canine, maxillary lateral incisor, mandibular first molar, and maxillary first molar tooth.[5]
Heithersay[6] classified ICR according to its extension into the root and proximity to the root canal into four types:
- Class 1: A small invasive resorptive lesion in the cervical area with little penetration into the dentin
- Class 2: A well-defined invasive lesion penetrating deeply into the dentin, close to the pulp, but without reaching the radicular dentin
- Class 3: A deep resorptive lesion invading the dentin and affecting both the coronal dentin and the coronal third of the root
- Class 4: A large invasive resorption extending beyond the coronal third of the root.
The detection of ICR is usually an incidental finding, as majority of patients are asymptomatic and presents no classic, clinical, and radiographic findings. However, the patient may manifest symptoms of irreversible pulpitis or apical periodontitis in advanced cases when the pulp becomes secondarily involved.[1] ICR may sometimes be misdiagnosed as buccal caries because of its location and similar radiological appearance, which may lead to inappropriate management of the lesion.[6] The presence of an intact root canal wall which is traceable throughout the lesion is pathognomonic of ICR and differentiates it from internal inflammatory resorption.[1]
The present case report describes the multidisciplinary approach for the successful management of ICR.
| Case Report | | |
A 21-year-old female patient reported to the department of conservative dentistry and endodontics with the chief complaint of pain and mobility in the upper right front tooth region. The patient recounted experiencing dental trauma injury 5 years back, and he remained asymptomatic before experiencing the current symptoms. Medical history was taken which was noncontributory. The patient's oral hygiene was poor. Tooth #11 showed a slight pinkish hue [Figure 1]a, and the tooth was tender on percussion. The tooth showed no response with heat or electric pulp testing. A preoperative radiograph revealed radiolucency at the cervical region of tooth 21 which was extending to the coronal third of the root [Figure 1]b. There was also a periapical radiolucency associated with tooth 11, 21, and 22. A clinical diagnosis of irreversible pulpitis of tooth 11, 21, and 22 along with ICR (Heithersay's Class III) of tooth 21 was made. Endodontic treatment of tooth 11, 21, and 22, followed by surgical curettage of periapical radiolucency and sealing of resorptive lesion was planned.
After taking verbal informed consent from the patient, local anesthesia (2% lignox, with adrenaline 1:80,000, Indoco Remedies Ltd., Mumbai) was injected. An access cavity was prepared after working length was determined with apex locator and was confirmed with 15k file radiographically. Chemomechanical preparation was done with hand K-files in crown down fashion up to 60k for tooth 11 and 21 and 50k for tooth 22. Irrigation was performed with 2% chlorhexidine digluconate for tooth 21 due to the presence of resorption and 1.5% NaOCL and 17% ethylenediaminetetraacetic acid (EDTA) for tooth 11 and 22. Teeth were then obturated using cold lateral condensation technique. Curettage of the periapical lesion and repair of the ICR was done immediately after endodontic treatment.
A mucoperiosteal flap was reflected [Figure 2]a, and curettage of periapical lesion was done. Then granulation tissue from resorptive cavity was removed and 3% sodium hypochlorite (Parcan, Septodont Healthcare India Pvt. Ltd., India) was applied with microbrush, followed by final rinsing with 17% EDTA. The resorptive area was filled with direct composite restoration [Figure 2]b and c]. Then, palatal flap was then raised to expose the defect on palatal side, and it was treated following same protocol as described previously for the buccal side [Figure 3]a and [Figure 3]b. Flap was then repositioned and sutured [Figure 3]c and [Figure 3]d, and the patient was recalled after 5 days for suture removal. Crown fabrication was done after 1 month. During the follow-up at 6 months and 1 year, the patient was completely asymptomatic, probing depth was within normal limit, and healing of periapical radiolucency [Figure 3]e was appreciated indicating the successful management of ICR. | Figure 2: (a) Photograph after raising the buccal flap. (b) Sealed buccal defect with composite. (c) Postobturation radiograph
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 | Figure 3: (a) Palatal flap raised showing palatal defect. (b) Sealed defect using composite. (c) Photograph after suture placement. (d) Postcrown fabrication radiograph. (e) 1 year follow-up radiograph
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| Discussion | | |
Proper clinical diagnosis and treatment planning is prerequisite for the successful clinical management of ICR. In this case report, surgical repair with root canal treatment was the preferred treatment approach as resorptive lesion was extensive, and the radiograph shows evidence of periapical pathosis. Other treatment modalities include internal repair, replantation, and extraction.[1]
The patient was asymptomatic and did not seek dental treatment for 5 years after the episode of traumatic dental injury. The inflammatory reaction aided by bacterial invasion of necrotic pulp in a traumatically injured tooth over a sustained long period could be the attributed factor for the resorptive defect in the present case.
In the present case report, ICR was associated with pulpal necrosis and periapical lesion. Surgical reflection of mucoperiosteal flap allowed repair of the resorption defect as well as simultaneous surgical curettage of the periapical lesion.
In this case report, 3% sodium hypochlorite (Parcan, Septodont Healthcare India Pvt. Ltd., India) was applied by micro brush, followed by 17% EDTA (Prime Dental product Limited, India) to fix any granulation tissue left after curettage, thus preventing its revascularization and recurrence. The use of micro brush helps in careful placement of 3% sodium hypochlorite, so that neighboring soft tissues are not damaged. The advantage of using 3% sodium hypochlorite was bifold as it fixes the tissue as well as arrests bleeding. Other agents that can be applied on the cavity include 90% aqueous solution of trichloroacetic acid.[6]
Various materials such as mineral trioxide aggregate,[7] biodentine,[8] calcium-enriched mixture,[9] composite, and glass ionomer had been used for sealing the resorptive cavity after curettage. However, in this case report, composite was used to seal the defect as it reduces plaque formation as compared to other materials (Biodentine and glass ionomer) resulting in successful outcome.[10]
Cone-beam computed tomography (CBCT) has proved to be an important diagnostic tool in the diagnosis and management of ICR as it can detect true nature and extent of lesion and overcomes several limitations of radiograph. Conventional radiograph superimposes the buccolingual images, and the resorptive defect is only represented along the mesiodistal plane which can often be misleading regarding the true extension of the lesion. However, in this case report, CBCT was not done as the patient did not comply with the treatment plan. Thus, various radiographs were taken at appropriate period to determine severity and to assess healing of the lesion.
| Conclusion | | |
The treatment of extensive ICR presents a clinical complexity in its management. Treatment plan must be directed toward arresting the pathophysiologic progression of invasive resorption as well as restoration of the defect. Surgical intervention with composite restoration of an extensive Class 3 defect might offer predictable clinical success.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Patel S, Mavridou AM, Lambrechts P, Saberi N. External cervical resorption-part 1: Histopathology, distribution and presentation. Int Endod J 2018;51:1205-23.  |
| 2. | Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:27-37. |
| 3. | Andreasen JO, Heithersay GS, Bakland LK. Pathologic tooth resorption. In: Rotstein I, Ingle J, editors. Ingles Endodontics. 7 th ed. USA: Ilan Rotstein; 2019. p. 430. |
| 4. | Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors. Quintessence Int 1999;30:83-95. |
| 5. | Mavridou AM, Bergmans L, Barendregt D, Lambrechts P. Descriptive analysis of factors associated with external cervical resorption. J Endod 2017;43:1602-10. |
| 6. | Heithersay GS. Treatment of invasive cervical resorption: An analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999;30:96-110. |
| 7. | Baratto-Filho F, Limongi O, Araújo Cde J, Neto MD, Maia SM, Santana D. Treatment of invasive cervical resorption with MTA: Case report. Aust Endod J 2005;31:76-80. |
| 8. | Baranwal AK. Management of external invasive cervical resorption of tooth with Biodentine: A case report. J Conserv Dent 2016;19:296-9. [ PUBMED] [Full text] |
| 9. | Asgary S, Nosrat A. Conservative management of class 4 invasive cervical root resorption using calcium-enriched mixture cement. J Endod 2016;42:1291-4. |
| 10. | Espona J, Roig E, Durán-Sindreu F, Abella F, Machado M, Roig M. Invasive cervical resorption: Clinical management in the anterior zone. J Endod 2018;44:1749-54. |
[Figure 1], [Figure 2], [Figure 3]
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