Treat or Extract: Invasive Cervical Root Resorption
Introduction
In 1979, Invasive Cervical Root Resorption (ICRR) was first documented in dental literature. ICRR presents as silent yet aggressive destruction predominantly affecting the cervical region of dental hard tissues, necessitating innovative diagnostic and treatment strategies. Left untreated, ICRR defects can enlarge and develop more root surface perforations, highlighting the need for timely intervention. Accurate diagnosis of ICRR requires a comprehensive approach merging clinical assessments with advanced imaging technologies.
Common Treatment Options
The treatment options for ICRR are diverse and contingent upon the extent and progression of the resorption. Monitoring, nonsurgical endodontic approaches, VPT techniques, and surgical interventions are among the strategies discussed. Nonsurgical endodontic approaches like external repair and modified root canal treatment are employed for lesions confined to certain regions, while VPT techniques focus on maintaining pulp vitality. Surgical interventions, often necessary for extensive lesions, include meticulous tissue removal and defect restoration using various biomaterials. Innovative regenerative techniques and multidisciplinary approaches, such as orthodontic extrusion combined with surgical exposure, may be required for severe cases. In some instances, we should go for extraction of the affected tooth. The internal method, a specialized approach for managing ICRR, involves accessing the resorptive lesion through the root canal system. This technique is particularly useful when the external approach is challenging due to the location or extent of the lesion. The procedure begins with conventional root canal treatment, followed by careful debridement of the resorptive tissue using specialized instruments. Calcium hydroxide is often used as an intracanal medicament to neutralize the acidic environment and promote healing. The defect is then sealed internally using biocompatible materials such as mineral trioxide aggregate (MTA) or biodentine. This method offers the advantage of preserving external tooth structure and may be combined with external approaches for comprehensive management of complex ICRR cases.
Treatment Outcomes
Effective ICRR treatment relies significantly on rigorous follow-up procedures, crucial for assessing treatment outcomes, monitoring potential resorption recurrence, and preserving tooth structure and function. In a study involving 94 patients with 101 affected teeth, the treatment approach encompassed root canal therapy, surgical methods including the topical application of trichloracetic acid, curettage, and restoration with glass-ionomer cement. Remarkably, this approach achieved a 100% success rate for class 1 and 2 ICRR lesions, a 78% success rate for class 3, while class 4 lesions exhibited only a 2% success rate. Surgical treatment was deemed inappropriate for class 4 and many class 3 ICRR cases due to extensive periodontal defects. It is worth noting that severe ICRR cases, while having a 50% survival rate, only showed a 12.5% overall success rate, often necessitating prosthodontic replacement. However, a recent systematic review, incorporating 66 case reports/series, indicated that nearly all treated cases of various ICRR severities were successful.
Mixed and Multidisciplinary Approaches
Cases involving severe ICRR may require a comprehensive, multidisciplinary approach. This approach combines the expertise of multiple dental disciplines, such as endodontics, orthodontics, periodontics, and prosthetics, as well as a combination of internal and external therapeutic access. An example of this approach is orthodontic extrusion with or without surgical techniques for exposing the ICRR rapidly from within the alveolar socket, reaching sound and healthy tooth material beyond the affected zone suitable for preparation and repair.
Patient Management and Perspectives
Recognizing and considering the patient’s viewpoint regarding diverse treatment options is of paramount importance. Engaging in comprehensive conversations that encompass the advantages and disadvantages of each treatment, expected outcomes, and post-treatment care is crucial for making well-informed decisions and ultimately boosting patient satisfaction. It’s important to note that, in light of the concept of minimally invasive endodontics and the successful outcomes associated with VPT, clinicians should encourage and guide patients toward minimally invasive endodontic options.
Prevention and Risk Factors
Preventing ICRR is a paramount concern within this domain. An in-depth comprehension of the risk factors that trigger ICRR is fundamental in establishing effective preventive measures. This section delves into the risk factors associated with ICRR and elucidates prevention strategies, underscoring the pivotal role of patient education and awareness.
So let’s review a real-life example by looking at a case report! This treatment was done by Dr. Omid Dianat, one of the authors of EndoTimes, and a recent review article on ICR (You can read the whole article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10787181/).
A CASE REPORT by Omid Dianat DDS, MS, MDS.
Here, we are reporting an ICRR case who was successfully managed at Irvine Endodontics (*Courtesy of Dr. Omid Dianat). Note that seeing this phenomenon on a radiograph is sometimes frustrating for a dentist, and the dentist might consider extraction right away. But isn’t there really any way to save this tooth? Well, let’s see!
Case overview and diagnosis
Patient Information:
59-year-old male
Referred to Irvine Endodontics (Dr. Omid Dianat)
Diagnosis: Invasive Cervical Root Resorption (ICRR) on tooth #12
Initial Presentation:
Radiographic findings: Radiolucency without direct caries indication
Note: ICRR can be challenging to diagnose
Diagnostic Procedures:
Initial 2D radiograph: Suspected external resorption
CBCT imaging: Revealed distobuccal extension with pulpal perforation (visible in axial, sagittal, and coronal views)
Treatment Plan: Two-visit approach (Combination of nonsurgical and surgical methods)
First Session
In the first session, we obtained radiographs and saw a radiolucency on tooth #12. From the 2D radiograph, we suspected that this was external resorption. To further inspect the tooth, we obtained a CBCT image. As you can see below, The lesion has a distobuccal extension with pulpal perforation as indicated in axial, sagittal, and coronal views. (Arrows show the lesion in each section).
Upon access cavity preparation, we were able to locate both palatal and buccal canals. We cleaned and instrumented the palatal canal followed by calcium hydroxide placement. However, the buccal canal preparation was not initiated for three reasons: 1. The communication between pulp and oral cavity through the resorption hampered proper isolation and made apt irrigation impossible. 2. This communication also increased the risk of contamination since microorganisms could still enter from the resorbed side. 3. The buccal canal was calcified, and it would be managed better in the second visit. Finally, the access cavity was covered with sponge and cavit.
The site of resorption was accessed through a triangular full mucoperiosteal flap. It was cleaned using bur and ultrasound tips and then permanently repaired using Geristore ® (A self-adhesive, dual-cure, resin-modified glass ionomer). The flap was sutured and the patient was scheduled for a second visit.
Second Session
The second session comprised of re-accessing the canals, cleaning, shaping, and final irrigation of buccal canal. Both canals were successfully located, rinsed, and shaped, followed by obturation with warm vertical condensation technique. The second session was practically as any other routine root canals that we do. After that, patient was sent back to GD and appointed one year recall examination. There has been no adverse effect so far, and we are looking forward to update this post with longer follow ups!
You can see before, post-surgery, master cone, and final radiographs below:
(Click on each radiograph to see them in full-size)
Clinical Significance
This case demonstrates the potential for tooth preservation in ICRR cases, highlighting the importance of accurate diagnosis and appropriate treatment planning. The combined endodontic-surgical approach proved successful in managing the resorptive defect and maintaining tooth function.
References:
Asgary S, Dianat O. Invasive Cervical Root Resorption: A Comprehensive Review on Pathogenesis, Diagnosis, and Treatment. Iran Endod J. 2024.
Smidt A, Nuni E, Keinan D. Invasive cervical root resorption: treatment rationale with an interdisciplinary approach. J Endod. 2007.
Huang J, Walsh RM, Witherspoon DE. The prevalence, characteristics, and risk factors of external cervical resorption: a retrospective practice-based study. Clin Oral Investig. 2023.
Asgary S, Roghanizadeh L. Successful Management of a Typical Class 3 Invasive Cervical Root Resorption with Modified Pulpotomy: A Case Report. Iran Endod J. 2024.
Karunakar P, Soloman RV, Anusha B. Endodontic management of invasive cervical resorption: Report of two cases. J Endod. 2018.
Jeng PY, Lin LD, Chang SH, Lee YL, Wang CY. Invasive cervical resorption—distribution, potential predisposing factors, and clinical characteristics. J Endod. 2020.
Irinakis E. External cervical root resorption: determinants and treatment outcomes. 2018.
Bachesk AB, Queiroz AF, Bin LR. Clinical approach to external cervical resorption in the anterior teeth: a case report study. Iran Endod J. 2021.
Interested in more cases?
You can find other cases that Dr. Dianat has previously published by clicking on the following links. You can also visit his Instagram page (https://www.instagram.com/endogram.drd/) and find out ICR cases alongside with other interesting daily cases!
Stay Tuned! We can’t wait to be back with another short clinical article!