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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 320-324

Management of unusual pattern of internal inflammatory tooth resorption and periapical cystic lesion – a unique case report

Department of Conservative Dentistry and Endodontics, Manubhai Patel Dental College and Hospital, Vadodara, Gujarat, India

Date of Submission24-Jun-2021
Date of Decision07-Aug-2021
Date of Acceptance13-Aug-2021
Date of Web Publication20-Dec-2021

Correspondence Address:
Avani Kamlesh Gorvadiya
5 OM, Akshar Marg, Indraprasth nagar, Near Satnam Hospital, Rajkot 360001, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_112_21

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Dental trauma is a challenge for dental integrity and can lead to various consequences, among which internal inflammatory root resorption can also be the fate of anterior teeth as they are commonly involved in traumatic events. The internal inflammatory root resorption occurs as a result of damage to the predentin due to trauma, plus root canal system becoming infected with bacteria. Trauma generates chronic inflammation, which leads to periapical inflammation and necrosis of epithelial cells, resulting in the formation of a cyst. The aim of the treatment approaches should be to assure complete biological healing and functional integration. This case report presents the unique characterization of traumatic consequences, including large periapical lesion and unique pattern of internal tooth resorption with intact apical barrier which was diagnosed by cone-beam computed tomography imaging and well managed by surgical intervention using mineral trioxide aggregate – both as a retrograde filling and tooth reinforcement material and sticky bone (platelet-rich fibrin + Bio-Oss) as a regenerative approach. The follow-up showed good results both clinically and radiographically. Thus, it can be concluded that endodontic reinforcement of thin roots due to internal resorption with intact apical barrier and surgical microendodontic procedure with regeneration is a potential therapeutic option in cases of traumatic injuries.

Keywords: Apical barrier, dental trauma, inflammatory root resorption, mineral trioxide aggregate, periapical surgery

How to cite this article:
Gorvadiya AK, Agrawal VS, Kapoor SV. Management of unusual pattern of internal inflammatory tooth resorption and periapical cystic lesion – a unique case report. J Dent Res Rev 2021;8:320-4

How to cite this URL:
Gorvadiya AK, Agrawal VS, Kapoor SV. Management of unusual pattern of internal inflammatory tooth resorption and periapical cystic lesion – a unique case report. J Dent Res Rev [serial online] 2021 [cited 2022 Dec 3];8:320-4. Available from: https://www.jdrr.org/text.asp?2021/8/4/320/332913

  Introduction Top

Dental traumatic injuries to the front teeth are one of the most devastating unplanned incidents that can result in pain, disfigurement, and psychological issues.[1] The pulp, periradicular, and soft tissues react negatively to trauma in different ways. The responses of these tissues will define the necessary therapy as well as the prognosis of the involved teeth.[2]

Due to partial or complete apical blood supply loss in traumatic lesions, pulp repair is uncommon in completely formed teeth, so pulp necrosis develops. By forcing leukocytes to develop into osteoclasts, bacterial toxins and by-products can promote inflammatory bone resorption without the involvement of osteoblasts, resulting in the creation of periapical cyst-like lesions.[2],[3] An intact tooth is typically resistant to resorption, even if the inflammation is present. Root resorption occurs when the protective layer of cementum/dentin is destroyed, causing inflammation of the pulp or periodontium.[1] The damaging process is accelerated when infection of the root canal space is paired with trauma-induced resorption, resulting in rapid tooth loss.[1] The majority of cases are asymptomatic until the late stages of resorption, and the pathologic process will continue if the inflammatory stimulation continues until no root structure remains.[1],[4]

Internal inflammatory root resorption can occur when the predentin is damaged by trauma, physical or chemical irritation, or bacterial infection in chronic pulpal inflammation.[5] As a result, endodontic therapy should be initiated as soon as the inflammatory stimulus is identified to eliminate inflammatory stimulus and prevent future radicular tissue loss. Endodontic surgery combined with root canal therapy has proven to be a highly successful treatment for periapical diseases with weeping canals.[6]

Having exceptional physicochemical and bioactive qualities, mineral trioxide aggregate (MTA) offers a significant benefit when utilized as a canal obturation material. As a result, MTA can be utilized as an obturating material using Bogen and Kutler's 2008 standard compaction process.[7] MTA is used as a root-end filling material in this scenario because of its remarkable biocompatibility, bioactivity, and capacity to stimulate differentiation and migration of hard tissue-producing cells. On the MTA surface, hydroxyapatite (or carbonated apatite) develops and provides a biological seal.[8],[9]

This case report presents the clinical and radiographic findings of damaged maxillary anterior teeth due to trauma and extensively impacted by internal inflammatory root resorption and periapical cystic lesion with successful surgical management and 16-month follow-up of the treatment.

  Case Report Top

A 35-year-old male patient came to the Department of Conservative Dentistry and Endodontics (Manubhai Patel Dental College, Hospital and ORI, Vadodara, Gujarat, India) with a chief complaint of pain and pus discharge from the attached gingiva in the upper front region of the tooth 21 for the past 5 days. The patient gave a past history of a traumatic injury 8 years ago, whereby he was hit by a cricket ball on upper front teeth region, after which he observed gradual color change of the tooth 21 turning dark brownish.

On clinical intraoral examination [Figure 1]a, the tooth 21 was presented with brownish discoloration of the crown which was nontender to percussion with no signs of mobility. The medical history of the patient was not significant. In radiographic examination, intraoral periapical radiograph [Figure 1]b reveals a large radiolucency associated with root apex of 21 and 22, widening of the canal from coronal to apical third and unique evidence of apical barrier in 21. Further examination with cone-beam computed tomography (CBCT) [Figure 1]c, [Figure 1]d, [Figure 1]e revealed the extent of the periapical lesion involving root apices of 21, 22, and 23, the size of the periapical lesion (12.5 mm bucco-palatally and 9.8 mm mesio-distally) and evidence of apical barrier. Thermal and electric pulp testing of 21, 22, and 23 showed a negative response. Based on clinical and radiographic examination, chronic apical periodontitis related to 21, 22, and 23 was concluded as the provisional diagnosis.
Figure 1: (a) Preoperative clinical picture, (b) preoperative periapical radiograph, (c-e) cone-beam computed tomography images in axial, sagittal, and coronal sections with three-dimensional reconstruction

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The treatment plan included endodontic treatment to remove the inflammatory stimulus (21, 22, and 23), surgical removal of the periapical cystic lesion due to the presence of weeping canal in 21 (apicectomy with MTA as a retrograde filling material), and scrutinizing the apical barrier. Before surgical intervention, informed consent and blood investigations were done (complete blood count), which revealed no information that may be used to dispute or affect the suggested treatment plan.

Under the rubber dam isolation, access preparation was performed without local anesthetic using a small round bur in 21, 22, and 23. Working length was taken first with an electronic apex locator (Root ZX II, J Morita, Kyoto, Japan) and confirmed radiographically (#15 k file, Mani, Tochigi, Japan). Cleaning and shaping was done using circumferential filing in 21 and a “step-back” method in 22 and 23 followed by copious irrigation with 5.25% NaOCl chloraxid (Cerkamed, Stalowa Wola, Poland) and normal saline. Nonsetting water-based calcium hydroxide (RC Cal, Prime, India) dressing was placed for a week. A day before surgery, 22 and 23 were obturated with cold lateral condensation technique and AH plus sealer (Dentsply Maillefer Ballaigues, Switzerland). Tooth 21 was not obturated and temporized (3M ESPE Cavit-G) to check the evidence of apical barrier during the surgery.

The surgical location had a sufficient mouth opening and adequate vestibule depth. To achieve the added benefit of decreased surgical bleeding, 2% lignocaine with 1:80,000 adrenaline (Lignox Adr 2%, Indoco Remedies Ltd.) was infiltrated in the alveolar buccal mucosa superficial to the periosteum at the level of root apices from 11 to 23. The buccal rectangular/trapezoidal flap design was selected and according to that, sulcular incisions were given from the distal aspect of the 11 to distal aspect of 23 with two vertical releasing incisions [Figure 2]a. With the help of a periosteal elevator, a full-thickness mucoperiosteal flap was raised, exposing the cortical bone and revealing cortical bone loss over the root of 21 as well as inflammatory granulation tissue adhering to the root apex of 21 [Figure 2]b. Using a surgical length round bur (Strauss 6 bladed operative and Surgical carbide cross round bur) in a straight handpiece at a slow speed, the exposed cortical bone over the periapical surgical site was removed [Figure 2]c. Throughout the cutting procedure, a sterile normal saline solution was used to provide constant irrigation.
Figure 2: (a) Incision, (b) flap reflection showing bone loss and cystic lesion, (c) curettage of the granulation tissue and osteotomy, (d) evidence of apical barrier, (e) root resection, (f) flap closure and suturing, (g) immediate postsurgical intraoral periapical showing mineral trioxide aggregate obturation irt 21

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The granulation tissue was curetted and the bleeding was controlled with an absorbable gelatin sponge. At the same time, the evidence of a closed apical barrier was investigated retrogradely [Figure 2]d. The enucleated granulation tissue was sent for histological assessment. In tooth 22 and 23, root-end preparation at an angle of 90° and 3 mm of root length was cut at low speed with a tapered surgical bur (Strauss 6 bladed operative and surgical carbide crosscut tapered fissure bur) to maintain maximal cemental coverage on the root surface and to maintain the original root length to promote tooth stability. The gutta- percha over the exposed root apex was cold burnished [Figure 2]e. Irrigated with sterile normal saline and carefully dried with moist gauze, the bone cavity was cleaned.

Root-end cavity preparation was done using Satelec Endo Success Apical Kit which contains diamond-coated ultrasonic tips (Satelec, Acteon, French MEDTECH) in tooth 22 and 23. The MTA (MTA Plus, Prevest DenPro, Jammu, India) was manipulated and placed as a root-end filling material according to the manufacturer's instructions. Simultaneously, 21 was orthograde obturated with MTA (MTA Plus, Prevest DenPro, Jammu, India) to reinforce the tooth root strength. To enhance the bone healing and to fill the bony defect, Geistlich Bio-Oss – a combination of hydroxyapatite and beta-tricalcium phosphate (Geistlich Pharma, Wolhusen, Switzerland), an alloplastic osteoconductive material, was mixed with small-sized cut platelet-rich fibrin (PRF), which was condensed well against the wall of the bony cavity, over which, the remaining PRF membrane was placed as a barrier which was collected on the same day before surgery.

The flap was repositioned, and the borders of the flap were examined to ensure that they were resting on the healthy bone. Interrupted 5-0 silk sutures were used to close the flap [Figure 2]f. To ensure well-condensed MTA and appropriate root-end filling, an intraoral periapical (IOPA) was taken [Figure 2]g. Both verbal and written postoperative instructions were given to the patient. Antibiotics, analgesics, and mouthwash were prescribed and the patient was instructed to report after a week for suture removal. Healing of the covering mucosa with primary purpose was observed on the 7th postoperative day, sutures were removed, and IOPA was taken. According to the histopathological analysis, the final diagnosis was made as an infected radicular cyst.

Periodic clinical and radiographic follow-ups were obtained at 4, 6, 8, and 16 months. The patient was free of all the symptoms and signs at the 4-month follow-up session, with optimum tissue healing [Figure 3]a and [Figure 3]b. The size of the periapical radiolucency surrounding the 21-tooth root was found to be gradually decreasing on the periodic radiographic evaluation. At 16-month follow-up visit, a remarkable bone healing was appreciated [Figure 3]c. Esthetic rehabilitation will be carried out along with further follow-up examinations.
Figure 3: (a and b) Four months of clinical and radiographic follow-up, (c) 16 months of radiographic follow-up

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  Discussion Top

Internal inflammatory root resorption and radicular cyst occur as a result of damage by traumatic injuries.[5],[10] In this case report, evidently both can be seen as a sequela of trauma.[11]

A recently proposed classification by Lindskog[12] divided the resorptions into three broad categories: (1) trauma-induced tooth resorption; (2) infection-induced tooth resorption; and (3) hyperplastic invasive tooth resorptions. Internal inflammatory (intraradicular and apical) and external inflammatory root resorptions are two types of infection-induced tooth resorption. Based on the clinical history and examination of the CBCT, the internal root resorption in this instance was categorized as internal inflammatory root resorption.

The dentoalveolar apparatus response to infection is characterized by inflammation, which can contribute to tooth resorption. Internal inflammatory resorption that is totally contained within an otherwise undamaged root is referred to as intraradicular internal inflammatory resorption. Internal resorption caused by infection can be identified as a round or oval radiolucency within the tooth root. In our case, the pattern of resorption is diverse with intact tooth root. Hence, the resorption was classified as intraradicular internal inflammatory root resorption.[13]

A thorough clinical and radiographic examination can be used to diagnose internal inflammatory root resorption. An IOPA radiograph was inconclusive in two dimensions based on the extent of large radiolucency. To know the exact true location and nature of pathology involved,[14] CBCT has become an important diagnostic tool. In the present case, CBCT imaging was employed to get a preoperative assessment for a more complete investigation.[15]

Several treatment modalities are present based on the stimulating factors involved in the root resorption. In our case, trauma being the culprit behind the pulpal inflammation followed by pulpal necrosis, development of cystic lesion and resorption, the root canal treatment followed by surgical intervention was the treatment of choice. Accordingly, surgical intervention was selected for the management of the periapical lesion based on the extent and given indications of the lesion.[16]

Calcium hydroxide was used as an intracanal medicament to enable disinfection methods to work more effectively, preserve alkalinity, and necrotize leftover pulp tissue.[17]

MTA was used as an obturating material because of the significant and multifaceted benefits of MTA in the internal resorption instances.[18] Due to the small particle size of MTA, and particularly White MTA, the material can access and fill partially or completely anatomical spaces.[17],[19]

PRF is widely used because of the local and continuous stimulation of growth factors and proteins. Due to the role of PRF in acceleration of soft tissue and bone healing, PRF is needed for physiological wound healing and reparative tissue processes.[20],[21] Geistlich Bio-Oss osteoconductive characteristics promote effective and predictable bone regeneration. It has its topographic structure, hydrophilic characteristics, and biologic interaction, all of which assist dependable bone development. In conclusion, the treatment of inflammatory root resorption by removing the stimulatory factors with complete biomechanical preparation of the root canal, cyst removal, and MTA obturation was considered successful.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

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