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Table of Contents
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 83-88

Management of internal and external resorption with open apex

1 Department of Conservative Dentistry and Endodontics, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Periodontology and Implantology, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Ekta Aakash Sengar
Department of Conservative Dentistry and Endodontics, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Sant Tukaram Nagar, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_53_18

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Tooth resorption is a phenomenon resulting in the loss of tooth structure. A simultaneous occurrence of internal resorption and communicating external resorption is often challenging for a clinician. To elicit immediate root canal treatment is of utmost importance, followed by the repair of defect to achieve promising results. For successful outcome, thorough investigations and obtaining a three-dimensional view of the extent and location of resorption should be obtained in order to plan the treatment.

Keywords: Decalcified freeze-dried bone allograft graft, mineral trioxide aggregate, resorption

How to cite this article:
Sengar EA, Mulay S, Kulloli A, Ligade S. Management of internal and external resorption with open apex. J Interdiscip Dentistry 2019;9:83-8

How to cite this URL:
Sengar EA, Mulay S, Kulloli A, Ligade S. Management of internal and external resorption with open apex. J Interdiscip Dentistry [serial online] 2019 [cited 2023 Mar 28];9:83-8. Available from: https://www.jidonline.com/text.asp?2019/9/2/83/268373

   Clinical Relevance to Interdisciplinary Dentistry Top

During the course of the treatment there can be some unforeseen obstacles that a clinician might come across, which often puts a clinician in a state of dilemma in order to putforth the best treatment option for the patient.In order to procure a successful outcome in such cases thorough investigations and treatment plan and an multidisciplinary approach can provide good clinical outcome.

   Introduction Top

The American Association of Endodontists has defined tooth resorption as a condition associated with either physiological or pathological process that results in the loss of substance from the tissues such as dentin, cementum, or alveolar bone.[1],[2] Resorption is said to be internal if the original site of the resorptive process starts in the pulp and external if the resorptive process starts in the periodontal ligament.[3]

Simultaneous occurrence of internal and external resorption with apical breakdown that often results in open apex is a rare condition and is challenging for the clinician.

In this present case report, we shall be discussing an unusual simultaneous occurrence of noncommunicating internal and external resorption with open apex and its management.

   Case Report Top

A 26-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with the complaint of pain and discoloration in the upper front region of the jaw. She started feeling pain and pus discharge from the upper front region of jaw for 5–6 months. The discoloration was present from a longer duration of time. She had history of trauma when she was in her school where she fell on her face. Discoloration was seen within approximately 2 years from the trauma. The onset of pain was gradual. The intensity of discoloration had progressively increased. There were no aggravating factors and no medications were taken for the same.

On clinical examination, discoloration was present with 21 [Figure 1]a, obliteration seen on the attached gingiva, suggesting a history of sinus formation. No sinus opening present at the time of clinical examination, Ellis Class IV fracture was seen with respect to 21. Pain on percussion was negative. Periodontal pocket was absent. The tooth was immobile. On palpation, no hard- or soft-tissue swelling was present. Pulp sensitivity tests showed negative response with 21 and positive with 11, 12, and 22.
Figure 1: (a) Preoperative image showing discoloration, (b) intraoral periapical with 21, (c) cone-beam computed tomography image – axial and sagittal sections,, (d) cone-beam computed tomography three-dimensional reconstruction

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A conventional intraoral periapical radiograph was then advised for radiographic evaluation. Radiographic evaluation revealed ballooning of canal in the middle-third of the root. There was loss of apical patency. Discontinuity of lamina dura, irregular periapical radiolucency, was noted with respect to 21 extending up to the lateral border of 22 with external resorption of the root [Figure 1]b. Cone-beam computed tomography (CBCT) revealed loss of labial cortical plate with loss of apical seal leading to open apex which was not seen on two-dimensional imaging [Figure 1]c and [Figure 1]d.

Treatment plan

The treatment options taken into consideration were as follows:

  1. Nonsurgical endodontic treatment
  2. Endodontic treatment followed by surgical intervention.

On elaborate discussion, treatment plan[2] was finalized, as it had better prognosis in this case. The treatment procedure was explained to the patient and informed consent was obtained. Presurgical blood investigations (Haemoglobin Hb, Bleeding time BT, Clotting time, CT, and Blood sugar level BSL) were carried out. Fitness for surgery was determined.


Endodontic phase

First visit

Tooth 21 was isolated under rubber dam [Figure 2]a, access opening was then done from the palatal side using a round bur ISO #12 (Mani) and modified using a safe end bur ISO #24 (Mani). Wet canal was noted. The length of the canal was measured using a #25 K file (Dentsply) with a sharp 90° bend at the end of the file; the instrument was moved along the wall of root canal till a gentle tug was felt showing instrument engagement on the wall of the root canal. This was then confirmed radiographically [Figure 2]b. Cleaning and shaping was done with #50K and #50H file (Dentsply). Intermittent irrigation was done with normal saline (Baxter) followed by using 2% chlorhexidine (Ammdent). Ca(OH)2 was used as an intracanal medicament, mixed with chlorhexidine gel (Ammdent). The access cavity was temporarily closed with Cavit (3M ESPE) [Figure 2]c. The patient was then recalled after 1 week [Figure 2]d.
Figure 2: (a) Isolation under rubber dam, (b) working length, (c) intracanal medication with Ca (OH)2, (d) 1-week follow-up, (e) MTA apical plug, (f) postobturation radiograph

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Second visit

The patient was asymptomatic. The tooth was again isolated under rubber dam. Interim restoration was removed and the canal was found to be dry. Root canal was then irrigated using normal saline (Baxter). The canal was dried using Paper Points (Dentsply). Mineral trioxide aggregate MTA Plus (Prevest DentPro) was manipulated according to the manufacturer's instruction and placed with MTA carrier in the canal to form an apical plug of 4 mm [Figure 2]e. Intraoral periapical was taken to confirm the placement of the root end filling material. The canal was then coated with a Ca(OH)2-based root canal sealer Sealapex (SybronEndo) and backfilled using thermoplasticized gutta-percha E and Q, (Meta Biomed). Double seal was then given using resin-modified glass ionomer cement (3M Vitremer) at the level of CEJ and then composite resin (3M Filtek Z350) was placed over it [Figure 2]f.

Surgical phase

Surgical treatment was planned on the same visit. Local anesthesia was administered in the concentration of 2% adrenaline 1:200,000 (Themicaine). Crevicular incision on corresponding tooth and vertical releasing incisions were given [Figure 3]a. Full-thickness mucoperiosteal flap was raised followed by thorough curettage to eradicate the infected tissue and extruded MTA beyond the apex, followed by thorough irrigation. MTA was then burnished at the apex to form an apical seal [Figure 3]b and [Figure 3]c.
Figure 3: (a) Crevicular incision, (b) full-thickness mucoperiosteal flap raised, (c) extruded MTA removed and burnished, (d) platelet-rich fibrin placed with decalcified freeze-dried bone allograft bone graft, (e) sutures placed

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Platelet-rich fibrin (PRF) was prepared [Figure 4]a, [Figure 4]b, [Figure 4]c, mixed with decalcified freeze-dried bone allograft (DFDBA) bone graft and placed at the surgical site in order to heal the bony destruction [Figure 3]d. Resorbable sutures were placed using 4o vicryl [Figure 3]e. Moreover, a postsurgical radiograph and CBCT was immediately taken to ensure the apical seal [Figure 5]a, [Figure 5]b and [Figure 5]c. CBCT revealed complete seal at the apex. Postoperative instructions were given.
Figure 4: (a-c) Preparation of platelet-rich fibrin

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Figure 5: Immediate postoperative radiographic images. (a) Intraoral periapical, (b and c) cone-beam computed tomography

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Restorative phase

The patient was recalled after 3 weeks. Complete healing of the surgical site was seen with healthy normal gingival condition. Postendodontic restoration was then done using all-ceramic crown [Figure 6]a, [Figure 6]b, [Figure 6]c, [Figure 6]d.
Figure 6: (a) Crown preparation, (b) impression of the preparation, (c) temporization, (d) all-ceramic crown placement

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The patient was recalled for follow-up after 3 and 6 months. Tooth 21 showed completely asymptomatic behavior, as there was no pain, swelling or mobility, and healing of tissues was seen and tooth 21 was functionally stable [Figure 7]a and [Figure 7]b.
Figure 7: Six months follow-up. (a) Clinical image, (b) radiographic image

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   Discussion Top

Inflammatory resorption is a pathological process that takes place within the pulp chamber of the root canal system and associated with loss of periradicular dentin and inflammation in the periapical area leading to root resorption. Internal resorption is described as an oval-shaped enlargement within the root canal space or loss in apical patency and is usually undetectable and also asymptomatic and is accidentally reported during radiographic investigation.[3] When diagnosed, the prime aim is the removal of the causative agent and to arrest the cellular activity responsible for the resorptive activity.[4]

In the present case, the patient reported to the dental outpatient department only after experiencing pain and discoloration with the respective tooth. Such long-standing inflammatory condition is often challenging, and complete disinfection of the canal should be of prime concern. Various treatment protocols were taken into consideration for the respective case.

As conventional intraoral periapical radiograph provides only two-dimensional image, a three-dimensional view was needed[5]. Hence, CBCT was advised. On three-dimensional evaluation under CBCT, tooth 21 showed apical resorption leading to open apex. Due to long-standing inflammatory resorption, there was break in the labial cortical plate extensive internal resorption leading to ballooning of the canal.

Nonsurgical endodontic treatment was ruled out in this case due to break in the labial cortical plate, excessive root and bone resorption, and probability of apical extrusion of the root end filling material. Endodontic regeneration was not considered due to external inflammatory resorption. Thus, surgical treatment was planned for this case.

Achieving an apical seal with gutta-percha and root canal sealer as obturation materials, without the use of an apical barrier does not lead to a good long-term prognosis for such teeth.[6],[7] Hence, MTA (MTA Plus) was selected as a root end filling material in this case, as MTA is excellent biocompatible material and has shown great sealing ability in dye penetration and bacterial leakage studies even under blood-contaminated condition, and hence, it was the material of choice in this case.[8]

Combination of restorative materials has shown promising results for restoration of access cavity in order to decrease microleakage. Thus, a combination of glass ionomer cement and composite resin was used in this case.

DFDBA mixed with PRF membrane was placed in the bony defect. DFDBA has shown promising results in periodontal therapy and has been proved to be biocompatible and capable for the induction of new bone formation. It has shown to be both osteoconductive and osteoinductive.[9] Urist, through numerous animal experiments, concluded that DFDBA bone graft has the potential to initiate the formation of new bone by osteoinduction.[10],[11] Graft material induces host-undifferentiated mesenchymal cells to differentiate into osteoblasts with subsequent formation of new bone.[12] It also provides a scaffold for osteoconduction.

PRF consists of a fibrin matrix polymerized in a tetramolecular structure with incorporated platelets, cytokines, leukocytes, and circulating stem cells. Slow fibrin polymerization during PRF processing leads to the intrinsic incorporation of platelet cytokines and glycan chains in the fibrin meshes[13]. PRF, when compared to the other platelet concentrates, has the ability to progressively release cytokines during fibrin matrix remodeling.[14],[15] PRF organizing a dense fibrin scaffold permits a rapid angiogenesis and an easier remodeling of fibrin in a more resistant connective tissue. When mixed with the graft, PRF fragments serve as a biological connector between bone particles.[16],[17]

With good-quality endodontics, aseptic surgical procedure, functionally and esthetically sound postendodontic coronal coverage, this case of internal and external resorption of the open apex was treated successfully. Periodic follow-up indicated good bone fill in defect and healing pattern. On 6-month follow-up, clinical examination revealed healing of tissue, no pain, swelling, or mobility and tooth 21 was functionally stable. On radiographic examination, healing of the defect with tooth 21 was appreciated.

   Conclusion Top

A multidisciplinary approach can provide a good clinical outcome in complex cases of external and internal resorption with open apex otherwise having poor prognosis. Special diagnostic aids such as CBCT can detect early radiographic changes, extent of lesion, and prevent the further deterioration or complications.

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Ne RF, Witherspoon DE, Gutmann JL. Tooth resorption. Quintessence Int 1999;30:925.  Back to cited text no. 1
Bansal C, Bharti V. Evaluation of efficacy autologous plateletrich fibrin with demineralizedfreeze dried bone allograft in the treatment of periodontal intrabony defects. J Indian Soc Periodontol 2013;17:3616.  Back to cited text no. 2
Dube K, Shukla S, Paul B, Kapur C. Apexification of nonvital immature teeth. J Conserv Endod 2016;1:315.  Back to cited text no. 3
Gajiwala AL, Kumar BD, Chokhani P. Evaluation of demineralised, freezedried, irradiated bone allografts in the treatment of osseous defects in the oral cavity. Cell Tissue Bank. 2007;8:2330.  Back to cited text no. 4
Bernardes RA, de Moraes IG, Duarte MA, Azevedo BC, de Azevedo JR, Bramante CM, et al. Use of conebeam volumetric tomography in the diagnosis of root fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:2707.  Back to cited text no. 5
Vyavahare NK. Rare simultaneous occurrence of internal root resorption, external apical resorption, and open apex. Management with 2 year follow up. Dent Allied Sci.2017;4:39-43  Back to cited text no. 6
Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral trioxide aggregate. Pract Periodontics Aesthet Dent 2000;12:31520.  Back to cited text no. 7
Fuss Z, Tsesis I, Lin S. Root resorption diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol 2003;19:17582.  Back to cited text no. 8
Trope M. Root resorption due to dental trauma. Endod Top2002;1:79100.  Back to cited text no. 9
Thomas P, Pillai RK, Ramakrishnan BP, Palani J. An insight into internal resorption. ISRN Dent 2014;2014:759326.  Back to cited text no. 10
Urist MR. Bone: Formation by autoinduction. Science1965;150:8939.  Back to cited text no. 11
Rosenberg E, Rose LF. Biologic and clinical considerations for autografts and allografts in periodontal regeneration therapy. Dent Clin North Am 1998;42:46790.  Back to cited text no. 12
Sak M, Radecka M, Anna K, Al Momani. Tooth root resorption:Etiopathogenesis and classification. MicroMedicine.2016;4:2131  Back to cited text no. 13
Parmar A, Vadher R, Parmar G, Dhanak N. Management of internal resorption: Case report. Indian J Basic Appl Med Res.2014;3:38694.  Back to cited text no. 14
Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: A review. J Endod 2009;35:61625.  Back to cited text no. 15
Simonpieri A, Del Corso M, Sammartino G, Ehrenfest DM. The relevance of Choukroun's plateletrich fibrin and metronidazoleduring complex maxillary rehabilitations using boneallograft. PartI: A new grafting protocol. Implant Dent 2009;18:10211  Back to cited text no. 16
AlKahtani A, Shostad S, Schifferle R, Bhambhani S. Invitro evaluation of microleakage of an orthograde apical plug of mineral trioxide aggregate in permanent teeth with simulated immature apices. J Endod 2005;31:1179  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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