ligament (creating cementum and Sharpey's fibers) occurs simultaneously. If less than 20% of the root surface is involved, a transient ankylosis may occur,.
ENDODONTOLOGY Healing of external inflammatory root resorption - a case report Mithra N. Hegde * Deepak Pardal **
ABSTRACT Case report describes a radiographic follow-up of healing of external inflammatory root resorption on a permanent maxillary left central incisor following avulsion and replantation using Vitapex®. Since more than 20 % of root surface was resorbed the healing occurred in the form of replacement resorption. The most important factor influencing the prognosis of replanted teeth is the status of periodontal ligament cells. Thus the treatment should aim at minimizing the extra-oral dry time, storage of avulsed tooth in a suitable medium, physiologic splinting for a period of 7-10 days and early endodontic therapy. Although there is no treatment for replacement resorption, it is worth an effort to try slow down the resorption process and maintain the tooth as long as possible in the arch for esthetics, functional and psychological reasons.
INTRODUCTION
surface is involved, a transient ankylosis may occur,
Facial trauma often results in the complete
which can later be resorbed due to functional
avulsion of a maxillary permanent incisor. The
stimuli, provided the tooth in the healing period is
reported incidence of tooth avulsion ranges from
stabilized with a splint which allows a minimum
1% to 16% of all traumatic injuries to the permanent
amount of mobility, or is non-splinted5,6. But if the
teeth12. These teeth may be replanted. It is well
trauma is extensive involving more than 20% of root
known that the fate of a replanted tooth can cover
surface, an abnormal attachment can occur after
various healing categories such as; normal
healing. After the initial inflammatory response to
periodontal
resorption,
remove debris resulting from the injury, a root
inflammatory resorption and replacement
surface devoid of cementum results. Cells in the
resorption
healing,
surface
3, 4
.
vicinity of the denuded root now compete to repopulate it. Often cells that are precursors of bone
When extensive damage occurs to the
will move across from the socket wall and populate
innermost layer of the periodontal ligament,
the damaged root rather that slower moving
competitive healing events take place. Healing from
periodontal ligament cells. Bone resorbs and reforms
the socket wall (creating bone via bone marrow-
physiologically through out life. The osteoclasts in
derived cells) and healing from adjacent periodontal
contact with the root resorb the dentin. In the
ligament (creating cementum and Sharpey’s fibers)
reforming phase, osteoblasts lay down bone in the
occurs simultaneously. If less than 20% of the root
area that was previously root, eventually replacing
* Professor and Head. ** Postgraduate student Department of Conservative Dentistry and Endodontics, A.B Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore
34
ENDODONTOLOGY
HEALING OF EXTERNAL INFLAMMATORY ROOT RESORPTION - A CASE REPORT
it. This progressive effect of ankylosis on the avulsed
to 21. Tooth number 11 and 22 also showed
1
tooth is termed replacement resorption . The
periapical radiolucency. Electric and thermal pulp
prolonged non-physiological storage of avulsed
testing gave a negative response in relation to tooth
teeth before replantation results in total necrosis of
number 11, 21 and 22.
the periodontal ligament, and healing by
Access opening and a complete canal
replacement root resorption (i.e., repair) becomes
debridement was undertaken for all the three teeth.
the only option7.
Tooth number 11 and 21 were filled with Vitapex®
This case report presents a radiographic follow
and 22 was obturated using guttapercha (figure2).
up (12 months) of treatment of external inflammatory
Tooth number 11 was obturated using guttapercha
root resorption using Vitapex®.
at 6 month recall (figure 4). It was only after a 12 month recall (figure 5) that the intra-oral periapical
CASE REPORT
radiograph showed sufficient healing of external root
A healthy 22-year-old patient visited the
resorption in relation to 21 with replacement
Department of Conservative Dentistry and
resorption and so a permanent root canal filling in
Endodontics, A.B Shetty Memorial Institute of Dental
form of guttapercha was placed (figure 6). There
Sciences, Mangalore, with a chief compliant of
was no mobility and tenderness on percussion in
broken tooth in the right upper front region of the
relation to tooth number 21 at the 12 month recall.
oral cavity. History revealed that the patient had a
DISCUSSION
fall about three months back, following which
Unlike bone, which undergoes resorption and
avulsion of tooth number 21 and fracture (Ellis class
apposition as part of a continual remodeling process,
II fracture) of 22 occurred.
the roots of permanent teeth are not normally
The patient visited a hospital where the avulsed
resorbed. Only the resorption of deciduous teeth
tooth was replanted after an extra-oral time of more
before they are shed can be considered physiologic8.
than 1 hour. During this period avulsed tooth was not stored in any suitable medium, instead was held
Avulsion injuries pose a greater and serious
in hand. The replanted tooth was then non-
assault to the gingiva, the periodontal ligament and
physiologically splinted for a period of 15 days. No
the pulp9. In clinical studies, teeth replanted within
root canal therapy was done at this period.
5 minutes after avulsion had the best prognosis and the chance of pulpal and periodontal healing was
Although patient did not complain of any pain
inversely related to the stage of root development
but on clinical examination it was found that tooth
and the period of dry storage10,11. In the optimal
number 21 was tender on percussion and had grade-
scenario, the avulsed tooth should be replanted
I mobility. An intra-oral periapical radiograph
immediately or should be stored in a suitable
(figure1) revealed areas of radiolucency along the
physiological medium before replantation12,13. The
apical and lateral surface of root and surrounding
replanted tooth should be splinted flexibly to the
bone (moth eaten appearance) with loss of lamina
adjacent teeth for 7 to 10 days to enhance
dura suggesting external root resorption in relation
periodontal healing. If the tooth apex is closed or 35
ENDODONTOLOGY
Mithra N. Hegde, Deepak Pardal
almost closed, prophylactic root canal treatment should be carried out on the day of splint removal to prevent the onset of inflammatory root resorption13. Andreasen has shown that resorption defects occur on the root surface adjacent to the areas of damage to the periodontal ligament during avulsion or extended drying before replantation. Inflammatory resorption is a mechanism of eliminating infected calcified tissue from the body; osteoclasts acting as specialized macrophages Figure1. Pre-operative view
Figure2. Post-operative view
actively participate in the healing process to repair traumatized tooth and bone14. Dry extra oral time after avulsion in the present case was more than 1 hour and during this period tooth was not stored in any suitable medium instead was kept in hand, which caused the drying of the periodontal ligament cells. Splinting was done using rigid wires that did not allow for the physiologic movement of the tooth for a period of 15 days. Endodontic therapy was not performed until 3 months. It has been emphasized that endodontic therapy should be undertaken within 7-10 days after
Figure3. Post-operative View at 3 months recall
Figure4. Post-operative view at 6 months recall
replantation so as to remove the necrotic pulp tissue which could get infected and initiate inflammatory root resorption. As the patient in the present case presented with extensive external inflammatory root resorption on the first visit, long term calcium hydroxide treatment was planned using Vitapex®. Calcium hydroxide is one of the most effective materials for the treatment of external root resorption because of mainly two properties high calcium ion concentration and alkaline pH 15 . The specific mechanism of action of calcium hydroxide is still
Figure5. Post-operative view at 12 months recall
Figure6. Permanent restoration
debated. Several theories have been postulated to 36
ENDODONTOLOGY
HEALING OF EXTERNAL INFLAMMATORY ROOT RESORPTION - A CASE REPORT
explain its biological activity. One theory discusses
above all psychological uplift of the young minds.
its high alkaline pH, which is important in
CONCLUSION
stimulating matrix formation by the formative cells16.
The most important step in case of avulsion
Another theory postulates that a high pH neutralizes
injuries is the maintenance of viable periodontal
the acidic products of the resorptive cells, creating
ligament cells which could be achieved with an
an unfavorable environment for them17. Furthermore
early replantation of the tooth with minimum extra
calcium hydroxide may promote healing because
oral dry time. It is equally important to store the
of its antibacterial properties18. Seltzer and Bender
tooth in suitable storage medium. Physiologic
stated that the presence of Ca2+ ions may activate
splinting and early endodontic intervention has also
ATPase, which may then enhance dental tissue
got an effective role to play. Thus as the degree of
remineralization19.
trauma cannot be controlled it is the preventive ®
measures that enhance the prognosis of a replanted
(J.Morita) containing viscous mix of calcium
tooth. External inflammatory root resorption
hydroxide and iodoform in a syringe with disposable
involving more that 20% of root structure will
tips was used in the present case. The main
usually go for a replacement resorption. However,
A commercial product named Vitapex
®
ingredients of Vitapex are iodoform 40.4%, calcium
an effort should always be made to slow down the
hydroxide 30.3%, silicone 22.4% and others 6.9%.
resorption process because replantation can restore
Calcium hydroxide and iodoform has been thought
the patient’s esthetic appearance and occlusal
20
to have a synergistic antibacterial effect . It is radio-
function and the replanted incisor can remain
opaque so could be easily detected on an intra-oral
functional for some years.
periapical radiograph. However there is a need to
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ENDODONTOLOGY
Mithra N. Hegde, Deepak Pardal
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