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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 144-148

Novel tri-layered restorative technique for management of external inflammatory invasive cervical resorption

Department of Conservative and Endodontics, M. P. Dental College and Hospital, Vadodara, Gujarat, India

Date of Submission23-Jul-2020
Date of Decision04-May-2021
Date of Acceptance02-Jun-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Vineet S Agrawal
15, Sakar Bunglows, Nr Ward Office 6, Akota, Vadodara, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_64_20

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Invasive cervical resorption (ICR) is aggressive and expansionist variety of external tooth resorption that commences within the cervical region. The treatment goal must be complete elimination of all resorbing tissues and therefore the reassembling of the resorptive defect by the placement of an acceptable filling material to achieve desired function and esthetics. The restoration of the defect becomes demanding and strenuous if it extends coronally as well as radicular. This case presents the management of a Heithersay's Class 3 ICR in maxillary right central incisor using a surgical approach and restoration of defect with tri-layered combination of biodentine, resin-modified glass ionomer cement, and composite resin.

Keywords: Biodentine, invasive cervical resorption, surgical treatment

How to cite this article:
Agrawal VS, Vasavda K, Kapoor S. Novel tri-layered restorative technique for management of external inflammatory invasive cervical resorption. J Interdiscip Dentistry 2021;11:144-8

How to cite this URL:
Agrawal VS, Vasavda K, Kapoor S. Novel tri-layered restorative technique for management of external inflammatory invasive cervical resorption. J Interdiscip Dentistry [serial online] 2021 [cited 2022 Aug 13];11:144-8. Available from: https://www.jidonline.com/text.asp?2021/11/3/144/333342

   Clinical Relevance to Interdisciplinary Dentistry Top

  • Successful management of the invasive cervical resorption (ICR) depends on the proper diagnosis, case selection, and treatment plan
  • Interdisciplinary approach combining surgical technique with endodontic, novel tri-layered restorative technique and prosthetic rehabilitation for the management of ICR.

   Introduction Top

Invasive cervical resorption (ICR) is relatively uncommon, insidious, and often aggressive form of external tooth resorption,[1] that can occur in any tooth of permanent dentition. ICR is defined as “a localized resorptive process that commences on the surface of root below the epithelial attachment and coronal aspect of supporting the alveolar process, namely, the zone of the connective tissue attachment.” Damage to the protective cementum layer at the cervical region, exposing of the underlying dentine and subsequent invasion by the microorganisms leading to inflammation and activation of odontoclasts leads to resorptive activity.[1] Trauma, orthodontic treatment, intracoronal bleaching, and surgical procedures have been listed as potential predisposing factors for ICR.[2]

ICR is usually asymptomatic and often detected when the affected tooth displays a pink discoloration in the cervical region of the crown as highly vascular resorptive tissue becomes visible through the resorbed overlying dentine and enamel or on routine radiographic examination exhibiting an irregular radiolucency with ragged margins or “moth-eaten” appearance.[1],[3] Accurate diagnosis and treatment plan can be executed with three-dimensional (3D) imaging techniques, such as cone-beam computed tomography (CBCT), which indicates the exact extent of an ICR lesion and proximity of the lesion to the pulp space.[4]

Cessation of the resorptive process and restoration of the lost tooth structure will lead to successful management of ICR. Various materials have been promoted to seal the resorptive defect such as mineral trioxide aggregate (MTA), glass-ionomer cement, and calcium-enriched mixture.[5] A new bioactive cement, biodentine (Septodont, St. Maur-des-Fossés, France), can be a useful option since its properties such as compressive strength, elasticity modulus, and microhardness are comparable with that of natural dentine making it substitute for dentin. However, when the resorptive defect is invasive involving coronal and radicular portion both, use of combination of various materials become inevitable.[6],[7]

This case report presents a successful management of ICR in maxillary right central incisor surgically managed and restored using novel tri-layered restorative technique as shown in schematic representation [Figure 1].
Figure 1: Schematic representation of the tri-layered technique

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   Case Report Top

A 26-year-old male patient was reported to the department of endodontics with a complaint of slight discoloration of the upper right front teeth. The tooth was asymptomatic and the patient gave a history of a traumatic injury before 8–9 years whereby he was hit by the cricket ball in the upper anterior region. He also gave the history of dental treatment that was the root canal treatment and periapical surgery in the upper front region been performed before 8 years when he met with the accident.

On intraoral examination, pinkish discoloration was seen on the distolabial cervical region of the crown of 11, and a “catch” was detected with probe followed by subsequent bleeding [Figure 2]a. Fracture of the incisal edge of 22 was noted and palatally permanently restored access cavity was seen in relation to 13, 12, 21, and 22. While in 11, there was temporary restoration with exposed gutta-percha seen palatally [Figure 2]b. All the maxillary anteriors were nontender on percussion.
Figure 2: (a) Preoperative photograph (Labial view). (b) Preoperative photograph (Palatal view)

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Radiographic examination revealed well-obturated teeth 13, 12, 11, 21, and 22. Eleven showed an irregular radiolucency having a mottled appearance involving the coronal dentine and extending to the middle third of the root suggestive of ICR [Figure 3]. CBCT was performed to determine the extent and depth of the lesion in the three spatial levels. Based on the CBCT images and 3D reconstructions, a diagnosis of invasive cervical external resorption of Heithersay's[2] Class III and 3Bp (3D classification) of Patel et al.[8] was determined [Figure 4].
Figure 3: Orthopantogram showing radiographic irregular radiolucency in 11 from cervical to middle third of the root

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Figure 4: Cone-beam computed tomography images in axial, sagittal, and coronal sections with three-dimensional reconstruction

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Based on the management protocols suggested by Patel et al.[9] treatment plan included both the external and internal repair comprising endodontic re-treatment and surgical intervention for removal of the inflamed granulation tissue that occupied the lesion cavity and repair of the resorption defect with triple layer of biodentine, resin-modified glass ionomer cement, and composite resin in 11.

After obtaining consent from the patient for the surgical procedure, a rectangular full-thickness labial mucoperiosteal flap was reflected following infiltration anesthesia. Granulomatous tissue was seen involving the labial surface and part of the distoproximal surface [Figure 5]a. The necrotic tissue was scooped out with the help of a discoid excavator. The resorptive defect extended from the cervical one-third of the crown to the middle one-third of the root, involving the distoproximal line angle, with the defect becoming shallow toward the root [Figure 5]b. Old, contaminated obturation was removed with the help of h files from the canal, and the canal was disinfected using 5.25% sodium hypochlorite (Chloraxid 5.25%, Cerkamed, Poland) as irrigant during minimal instrumentation till ProTaper Next rotary files to size X2 (Dentsply Maillefer, Ballaigues, Switzerland). Obturation was completed using ProTaper Next X2 gutta-percha (Dentsply Maillefer, Ballaigues, Switzerland) and AH Plus (Dentsply Maillefer Ballaigues, Switzerland) as endodontic sealer but was kept below the level of resorption [Figure 5]c.
Figure 5: (a) Surgical exposure of resorption defect. (b) Curettage of the resorptive tissue (c) Obturation below resorptive defect area. (d) Placement of biodentine below cementoenamel junction. (e) Placement of RMGIC at cementoenamel junction. (f) Placement of csomposite restoration above cementoenamel junction

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A small cotton pellet was then dipped in 90% trichloroacetic acid and the excess was removed by dabbing it on a piece of gauze. The cotton pellet was then applied over the resorptive defect area with gentle pressure for about 1 min. The irregular borders of the defect were smoothed with a small round bur. Biodentine (Septodont, St. Maurdes Fossés, France) was mixed according to the manufacturer's instructions and was firmly condensed in the resorptive defect. Biodentine was contoured laterally and placed till the cementoenamel junction (CEJ) only covering only the resorptive defect on the root surface [Figure 5]d. Biodentine was left for 15 min to achieve the initial setting and relative hardness. After the setting of biodentine was confirmed, Resin-modified glass ionomer cement (GC Gold Label 2 LC, GC Corporation, Tokyo, Japan), was placed over the biodentine at the CEJ level [Figure 5]e. Rest of the resorptive defect over the CEJ level on the coronal aspect over the clinical crown was restored with G-aenial anterior (GC, Tokyo, Japan) composite after applying bonding agent G-aenial Bond (GC, Tokyo, Japan) [Figure 5]f.

Finally, the flap was sutured with 3-0 black silk suture material and the patient was instructed to report after a week for suture removal. Postoperative intra-oral periapical radiograph radiograph was taken [Figure 6]. The patient was recalled at 3 months for follow-up and the prosthetic crown was fabricated for 11.
Figure 6: Immediate postoperative radiograph

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At 1-year follow-up, the patient was completely asymptomatic. Clinical and radiographic evaluation did not reveal any recurrence of the resorption, gingival healing appeared complete with normal probing depth and no loss of clinical attachment [Figure 7].
Figure 7: One year follow-up clinical and radiographic images

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   Discussion Top

The damage to the cemental layer exposing the dentin and the superimposition by bacteria remains to be the etiological factor for the development of the ICR.[1],[3] In our case, the history of trauma might be the cause that had damaged the cemental layer of the tooth and inappropriate coronal seal (exposed gutta-percha) was supposedly led to the bacterial infection leading to inflammation and the progression of the cervical resorption.

Different treatment modalities have been suggested by several authors for the treatment of ICR, but the basic aim is the complete removal of resorptive tissue and the restoration of the defect area.[7],[10] In our case, being ICR, which has destructed majority of the tooth structure below the CEJ, surgical exposure was planned followed by restoration with three-layered restorative materials.

The debrided resorption defect comprised a coronal and radicular portion, involving the distal proximal line angle. After surgery, Biodentine was selected as the material for the restoration of the resorbed area over the root surface, as it can be placed in permanent and close contact with periradicular tissue due to its bioactivity and biocompatibility. Dentin-like mechanical properties advocate its use as a dentin substitute on crowns and roots. Compared with other bioactive materials such as MTA, Biodentine handles easily and needs much less time for setting. Its property to release calcium ion and enhancing the alkaline environment makes Biodentine more conducive for osteoblastic activity. Furthermore, calcium and hydroxide ions stimulate the release of pyrophosphatase, alkaline phosphatase, and bone morphogenetic protein-2, which favors the regeneration and mineralization process.[7],[11] However, the entire defect could not be restored with biodentine due to the coronal extent of the defect; Biodentine if placed on the coronal aspect cannot be polished and the rough surface of biodentine promote the development of sub-gingival plaque and its constant exposure to the oral environment. Hence, a combination approach was used to restore the defect. The resin modified glass ionomer cement framework divided the defect into coronal and radicular cavities. RMGIC layer was placed between coronal and radicular cavities as it provides adhesion to the tooth structure, esthetics, fluoride release, and a surface which can be etched and bonded for subsequent resin restoration.[12],[13] Rationale of using RMGIC over biodentine was to protect composites against biological fluids such as gingival crevicular fluid which may hamper the direct adhesion of composite to biodentine. Because of the inadequate sealing ability of composites against biological fluids and poor biocompatibility it was not used directly in the CEJ area. Composite resins are generally used in defects in the coronal region as they can be greatly polished and esthetically give good results, but not biologically acceptable in periodontal tissues hence cannot be placed in subgingival regions.[13],[14]

The rationale for using trichloroacetic acid to remove or inactivate the resorbing tissue lies on the fact that it being a chemical escharotic agent renders the tissue avascular by a process of coagulation necrosis. The self-limiting necrosis zone is well demarcated from the adjacent tissue, and therefore an uncomplicated repair of the surrounding periodontal tissue can be expected.[15]

Finally, treatment of the invasive cervical resorptive defect restored with three-layered technique was considered successful as evidenced by clinical and radiographic findings after 12 months. Although frequent annual follow-ups are required for determining the success and prognosis of the treatment.

   Conclusions Top

The successful outcome and long-term retention of the ICR depend on the proper diagnosis, case selection, and treatment plan. The successful outcome in this case with novel tri-layered restorative technique for treating ICR, supports the use of this technique in such cases.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:27-37.  Back to cited text no. 1
Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors. Quintessence Int 1999;30:83-95.  Back to cited text no. 2
Jeng PY, Lin LD, Chang SH, Lee YL, Wang CY, Jeng JH, et al. Invasive cervical resorption-distribution, potential predisposing factors, and clinical characteristics. J Endod 2020;46:475-82.  Back to cited text no. 3
Patel S, Dawood A. The use of cone beam computed tomography in the management of external cervical resorption lesions. Int Endod J 2007;40:730-7.  Back to cited text no. 4
Abbott PV. Prevention and management of external inflammatory resorption following trauma to teeth. Aust Dent J 2016;61 Suppl 1:82-94.  Back to cited text no. 5
Malkondu Ö, Karapinar Kazandağ M, Kazazoğlu E. A review on biodentine, a contemporary dentine replacement and repair material. Biomed Res Int 2014;2014:160951.  Back to cited text no. 6
Baranwal AK. Management of external invasive cervical resorption of tooth with Biodentine: A case report. J Conserv Dent 2016;19:296-9.  Back to cited text no. 7
[PUBMED]  [Full text]  
Patel S, Mavridou AM, Lambrechts P, Saberi N. External cervical resorption-part 1: Histopathology, distribution and presentation. Int Endod J 2018;51:1205-23.  Back to cited text no. 8
Patel S, Foschi F, Condon R, Pimentel T, Bhuva B. External cervical resorption: Part 2-management. Int Endod J 2018;51:1224-38.  Back to cited text no. 9
Ikhar A, Thakur N, Patel A, Bhede R, Patil P, Gupta S. Management of external invasive cervical resorption tooth with mineral trioxide aggregate: A case report. Case Rep Med 2013;2013:139801.  Back to cited text no. 10
Bolhari B, Shokouhinejad N, Masoudi A. The effect of calcium hydroxide on the bond strength of resilon/epiphany self-etch and assessment of calcium hydroxide removal techniques: An ex-vivo study. J Dent (Tehran) 2012;9:150-5.  Back to cited text no. 11
Tavares WL, Lopes RC, Oliveira RR, Souza RG, Henriques LC, Ribeiro-Sobrinho AP. Surgical management of invasive cervical resorption using resin-modified glass ionomer cement. Gen Dent 2013;61:e16-8.  Back to cited text no. 12
Sharma R, Swami A, Smitha BV. Surgical root repair of extensive invasive cervical resorption defects involving the cementoenamel junction: Two case reports. Endodontology 2018;30:171-6.  Back to cited text no. 13
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Hommez GM, Browaeys HA, De Moor RJ. Surgical root restoration after external inflammatory root resorption: A case report. J Endod 2006;32:798-801.  Back to cited text no. 14
Heithersay GS. Treatment of invasive cervical resorption: An analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999;30:96-110.  Back to cited text no. 15


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


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