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 Table of Contents  
Year : 2017  |  Volume : 6  |  Issue : 1  |  Page : 39-43

Rare simultaneous occurrence of internal root resorption, external apical resorption, and open apex: Management with 2 years follow-up

1 Department of Conservative Dentistry and Endodontics, Sinhgad Dental College, Pune, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, IMS, B.H.U., Varanasi, Uttar Pradesh, India
3 Department of Conservative Dentistry and Endodontics, Azamgarh Dental College, Azamgarh, Uttar Pradesh, India

Date of Web Publication2-May-2017

Correspondence Address:
Akash Kumar Baranwal
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, IMS, B.H.U., Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-4696.205444

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Root resorption of the tooth may be a pathologic or physiologic process resulting in loss of root dentin and cementum. Broadly, it can be of two types – external and internal root resorption. The location of these resorptions can vary from cervical to apical region. Most often, the etiology of it may attribute to some kind of traumatic injuries. External apical resorption, if left untreated for a long period, may result in an open apex with the loss of normal apical constriction and this poses a problem while obturation due to the lack of apical stop. The case becomes of a big concern when such resorptions occur simultaneously along with open apex as these may produce difficulties while managing. Therefore, the objective of the present article is to discuss the root resorption and management of a rare case involving maxillary central incisor with internal root resorption, external apical resorption, and open apex with 2 years follow-up.

Keywords: External root resorption, internal root resorption, mineral trioxide aggregate, odontoclasts, open apex, ultrasonic agitation

How to cite this article:
Vyavahare NK, Baranwal AK, Lakiang R D, Hindlekar A. Rare simultaneous occurrence of internal root resorption, external apical resorption, and open apex: Management with 2 years follow-up. J Dent Allied Sci 2017;6:39-43

How to cite this URL:
Vyavahare NK, Baranwal AK, Lakiang R D, Hindlekar A. Rare simultaneous occurrence of internal root resorption, external apical resorption, and open apex: Management with 2 years follow-up. J Dent Allied Sci [serial online] 2017 [cited 2023 Jun 5];6:39-43. Available from: https://www.jdas.in/text.asp?2017/6/1/39/205444

  Introduction Top

As per described by the Glossary of the American Association of Endodontists, resorption is a condition associated with either a physiologic or a pathologic process resulting in loss of dentin, cementum, or bone. Depending on its location in association to the root surface, root resorption may either be internal or external. The internal resorptive lesion may be inflammatory or replacement type. Whereas, the external resorption can be categorized into external surface resorption, external inflammatory resorption, external replacement resorption, external cervical resorption, and transient apical breakdown.[1],[2]

The etiology of external resorption may be attributed mostly to local factors, but some systemic factors may also contribute. Under local factors teeth impaction, orthodontic treatment, cysts and tumors, periradicular inflammatory conditions, luxation or reimplantation of tooth, periodontal disease, and tooth bleaching may lead such resorptions. Some systematic factors such as hypo- and hyperparathyroidism, Turner's syndrome, Gaucher's disease, and Paget's disease have also been found contributing the external root resorption.[3]

On the other hand, the etiology and pathogenesis of internal resorption are not very clear; it is usually a result of chronic infection or trauma. On radiographic interpretation, internal resorption seems to be well-delineated, round-to-oval radiolucent enlargement or ballooning out of the pulpal canal space and it shows continuity with the canal wall itself.[4],[5] Often, few cases of tooth resorption having unknown etiology may be categorized as idiopathic root resorption.[6]

The idiopathic root resorption may be divided into apical and cervical types. Cervical resorption affects the cervical area of a tooth, and it may progress to involve the pulp, whereas apical resorption degrade the apical portion of tooth root and may result in root length reduction.[7] The patient affected with idiopathic root resorption usually shows asymptomatic behavior and often complaining of tooth mobility. Most of the time, such resorptive defects are detected on routine radiographic check-ups and these defects may occur in the posterior or anterior quadrants or all teeth.[8],[9]

To decide a definite management of the affected tooth, radiographic diagnosis is of utmost importance. For this, conventional radiographic techniques are mostly used to detect root resorption.[10],[11] Since it has demerit of being two dimensional only, the detection of external and internal root radiolucencies at an early stage are typically not possible.[1],[12]

Clinically, the tooth resorption may remain unnoticed for several years because of its asymptomatic nature. The patient's history has an importance for the clinician to have an idea about the last worked done on the tooth or the role of any traumatic incident. The patient may feel pain only if the lesion is having significant pulpal inflammation. The resorption may continue as the vitality of tissue is maintained and finally may invade the tooth root structure to reach the periodontal ligaments (PDLs).[13]

Considering the treatment, pulpectomy should be the preferred option in case of an internal resorption detected radiographically. If the resorption has not progressed into a large defect, the resorption can be overcome by an endodontic treatment.[14]

In case of external resorption usually, when the cause is detected, removing such factor may treat the lesion.[3] Moreover, managing such defects at an early stage, before any significant root structure loss, the prognosis becomes excellent, otherwise delay in treatment may have a poor prognosis. Because of different pathologic processes of internal and external resorption, the separate treatment protocols are needed, and accurate diagnosis becomes essential for producing an excellent outcome.[15]

The ultimate aim for the external apical root resorption treatment is to destroy the bacteria completely to promote healing within the periradicular space.[16] Nonsurgical root canal therapy along with intracanal calcium hydroxide medicament was recommended by Andreasen as calcium hydroxide is best capable of destroying the bacteria.[17] However, long-term application of calcium hydroxide may cause weakening of the root structure in immature teeth.

Often, the apical external root resorption, if not treated at the time, may result eventually the loss of an apical stop or an open apex which may further make the case more complicated. Without creating a calcified apical barrier, obtaining an apical seal with gutta-percha and root canal sealer as obturation materials cannot offer a good long-term prognosis for such teeth.[18] Developing artificial apical barriers using bioactive materials such as mineral trioxide aggregate (MTA), biodentine and calcium-enriched mixture have been suggested before obturation of the rest of the root canal.[19]

MTA with its excellent biocompatibility nature has already shown great sealing ability in dye penetration and bacterial leakage studies even under blood contaminated conditions.[20],[21] MTA material has a wide range of clinical applications including the root-end filling, perforation repair, and pulp capping, etc., It has the capability of inducing regeneration of periradicular tissues, such as bone and cementum.[20],[21],[22] Although properties of MTA are very well mentioned in the literature, the use of MTA for internal and external root resorption management has not been performed so frequently.

Therefore, in the current case report, we discuss the management of a rare case of maxillary central incisor diagnosed with a combination of internal root resorption, external apical replacement resorption, and open apex using MTA with 2 years follow-up.

  Case Report Top

A 25-year-old female patient reported to the Department of Conservative Dentistry and Endodontics, with a chief complaint of discolored upper front tooth. Patient's medical history was noncontributory. She gave a history of trauma 9 years back during sport activities and refused to have any kind of dental treatment till reporting date. On intraoral clinical examination, the right maxillary central incisor, i.e., 11 was found discolored without any tenderness on both lateral and vertical percussion. There was no associated swelling or sinus, and the mobility of tooth was within the normal range. The clinical examination also revealed normal adjacent teeth, a moderate oral hygiene, and healthy gingival tissues.

The patient was advised for an intraoral periapical (IOPA) radiograph of the maxillary incisors [Figure 1]a, the interpretation of which revealed a wider root canal with a definite and enlarged rarefaction in middle portion of root canal indicative of radiographic presentation of internal root resorption. At the same time, the flat root apical portion along with shortening of root was also noticed suggesting for an apical external root resorption. However, the lost apical root portion on IOPA radiograph gave the indication of its replacement with bony trabeculae structures, hence, the provisional diagnosis of apical root replacement resorption seemed to be appropriate. Furthermore, the presence of wide open apical root portion was detected along with external apical resorption. Another associated positive radiographic finding included the slight widening of PDL space in relation to 11, but it denied the sign of any root or tooth fracture. The patient was informed about the current diagnosis and prognosis of the tooth. In addition, a conservative orthograde endodontic treatment option was provided to the patient including apical stop creation with MTA, filling of the internal resorptive defect and root canal with dual cure resin followed by fixed crown. The patient was willing to save the tooth, hence she opted the same.
Figure 1: (a) Preoperative intraoral periapical radiograph. (b) Working length determination (c) Intra-canal calcium hydroxide medicament. (d) Placement of mineral trioxide aggregates apical plug. (e) Postoperative intraoral periapical radiograph. (f) Intraoral periapical radiograph after 2 years follow-up

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First visit

After giving local anesthesia (Lignocaine, 1:200000) (Lox, Neon Laboratories Ltd.) the concerned tooth, i.e., 11 was isolated with rubber dam (Hygenic, Coltene Whaledent). The access cavity of 11 was prepared from the palatal side using endo-access kit and achieved a straight line access to the apical root portion.

The initial working length was predicted using K-file and was confirmed with IOPA radiograph [Figure 1]b. Gentle instrumentation was done with #120 K-file. During the instrumentation, 1.5% diluted sodium hypochlorite (NaOCl) (Percan, Septodont) and 2% chlorhexidine (Chlor X, Prevest DenPro Ltd.) irrigation was done alternatively with normal saline in between the irrigants using Max-I-Probe. At the end, normal saline was used as final irrigation. During the procedure, the irrigants were ultrasonically agitated to enhance the removal of necrotic debris and microbial reduction from the inaccessible internal resorptive defect area (i.e., after gentle root canal instrumentation, a suitable K-file was introduced in the center of the root canal, as far as the apical region. The root canal is then filled with the irrigant solution, and the file was ultrasonically oscillated which activated the irrigant. With this technique, the file moves freely and the irrigants penetrate more easily into the apical and resorptive part of the root canal system, and the cleaning effect becomes more powerful).

Now, the prepared canal was completely dried with absorbent paper points, and an intracanal medicament of Ca(OH)2(Apexical, Ivoclar Vivadent) was filled completely within canal to achieve proper disinfection [Figure 1]c. Access cavity was sealed temporarily with Cavit-G and patient was recalled after 2 weeks.

Second visit

Tooth was again isolated with rubber dam, opened and canal thoroughly irrigated with saline to remove any remnants of calcium hydroxide. Final irrigation was done with diluted NaOCl followed by normal saline using again the ultrasonic agitation technique.

After drying canal, MTA (MTA Angelus) was manipulated (according to manufacturer's instructions) and then incrementally placed into the canals with sterilized amalgam carrier to form an apical plug of approximately 5 mm [Figure 1]d. Moist cotton was placed in contact with MTA within the canal and closed dressing was given.

Third visit

At the next day, the setting and consistency of MTA apical plug were checked clinically with the help of probe. After confirmation of MTA setting, the whole root canal including the internal resorptive defect was filled with dual cure resin (Paracore, Coltene Whaledent). For this, the root canal was prepared using nonrinsing conditioner (Parabond) of Paracore kit followed by bonding agent (Parabond, Coltene Whaledent) application and light curing. Now, the dual cure resin cement was dispensed from dual cure resin syringe using long dispensing delivery tip within the resorptive canal up to access opening. The delivery tip was inserted within canal and was moved from the inside out 2–3 times for proper flow of resin cement within canal and to prevent voids. It was then light cured for 40 s [Figure 1]e.

For the esthetic correction, the next phase involved proper shade matching and tooth preparation for porcelain fused to metal (PFM) crown using crown reduction kit (Shofu, Japan). Impressions were made and send to the dental laboratory for crown fabrication following proper disinfection protocol. At the final visit, the PFM crown was luted to prepared tooth. Finally, the patient was advised to come for regular follow-up at 3 months, 6 months, 1 year, and 2 years.

  Discussion Top

Tooth root resorption may be a pathological process of either internal or external type. When the predentin and odontoblasts layer in the root canal is disturbed, internal resorption may happen as a result of embryonic connective tissue cells transformation into giant multinucleate odontoclasts. These activated multinucleate giant cells start resorbing the internal aspect of root canal space adjacent to the granulation tissue in the inflamed pulp.[14]

Since internal resorptive lesions have less dentin thickness and concavity defects, they pose problems while instrumentation and filling compared to normal root dentin. In addition, such lesion may be the reservoir of granulation tissues and clastic cells, the complete elimination of these becomes much necessary.[23] On the other hand, when the balance between osteoblastic and osteoclastic functions, responsible for the physiological state of the root and bone, is disrupted, this may cause the removal of the precementum and cementoblasts from the root surface resulting in external root resorption.[14]

Early diagnosis or detection of root resorption is important as it may create problematic situation for dental clinicians. Here, in the present case, the patient did not undergo for any dental check-up after having trauma to the particular tooth, and she reported to the department only after observing the discoloration of the injured tooth. After the IOPA radiographic interpretation of 11, the presence of internal resorption along with external apical replacement resorption was detected. Due to the absence of early detection and intervention for a long period, the external resorption led to root shortening and the loss apical stop too, i.e., an open apical root. The immediate or earliest reporting of the patient could avoid the external resorption and its consequences. Hence, the management of such defects should be started immediately as soon as diagnosed and the utmost aim of treatment should direct toward the complete cessation of osteoclastic activities to stop any further progression of the resorptive lesion.

The endodontic management of the present case involved thorough chemomechanical preparation with gentle instrumentations to preserve the apical root dentin thickness, intracanal medicament placement within canal to achieve proper disinfection and osteoclastic activity cessation as well, creation of apical stop with MTA apical plug followed by internal resorptive defect and complete canal filling with dual-cure resin. Later, PFM crown of proper shade was luted to prepared tooth to overcome the coronal discoloration.

Ultrasonic agitation of irrigants, i.e., passive ultrasonic irrigation (PUI) was used in this case for thorough removal of necrotic debris from resorptive defect. Rödig et al.[24] have confirmed PUI as more effective method than syringe irrigation while removing debris from extensions in straight root canals.

To overcome the problem of the open apical end, creation of artificial apical barrier using bioactive material like MTA has been suggested before obturation of the rest of the root canal. MTA, because of its excellent biocompatibility, sealing ability, regenerative potential and single visit application, becomes the superior material than calcium hydroxide. At the beginning, long-term calcium hydroxide applications within canal were in tradition, but these procedures might alter the mechanical properties of dentin and make these teeth more susceptible to root fracture, hence, it cannot be a preferred choice.[19],[25]

Resin-based restorative material (dual cure resin) was considered for this case to fill the resorptive defect because of several advantages such as suitable elastic modulus, esthetics, good bonding of cement and root dentin, lower chair time, and minimal tissue removal.[26] The flowable property of resin material helped in filling the resorptive defect and allowed it to adapt the walls completely.

At the follow-up visits, the endodontically managed resorptive tooth, i.e., 11 showed completely asymptomatic behavior. The IOPA radiographs taken at successive follow-up visits did not represent any sign of further internal as well external resorptive progression of root structure, and rather, gave the sign of apical root end closure. The final IOPA radiograph of 11 at 2 years follow-up, clearly demonstrated the complete apical root closure, a significant reduction in the PDL space width along with normal periradicular bony architecture [Figure 1]f. Although there was no increase in root length, the root end closure along with sufficient apical root width enhancement, recovery of normal PDL space, normal surrounding bony structure and complete absence of clinical sign or symptoms support the successful management of the tooth.

  Conclusion Top

This report presented a case of combined internal and external root resorption along with open apical end, which was a rare clinical process that needed a definite management plan. Some special diagnostic aids like cone beam computed tomography can detect early radiographic changes related to traumatized tooth to initiate early interventions and to prevent the further resorptive deterioration or complications. Considering the responsible mechanism behind the lesion, the treatment approach of such cases should be based on the immediate intervention once diagnosed, so that it may result in a successful and prolonged outcome.

Financial support and sponsorship

Department of Conservative Dentistry and Endodontics, Dr. R. Ahmed Dental College and Hospital, Kolkata - 700 014.

Conflicts of interest

There are no conflicts of interest.

  References Top

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