Recognising and treating invasive cervical resorption
Featured Products Promotional FeaturesPosted by: Dental Design 19th June 2022
Dr Cameron Currie is a highly experienced dentist who limits his practice to endodontics at Lodge Dental. He presents a complex case requiring endodontic treatment combined with a surgical restorative approach.
A female patient in her mid-50s presented to the practice with a subgingival defect under the veneer on her central incisor. Her general dentist believed decay was present, therefore rendering the tooth untreatable. They had referred the patient to a clinical dental technician (CDT) for provision of an immediate denture, to be fitted following extraction. He advised the patient to try and save the tooth in any way possible before committing to extraction and he recommended visiting me for a second opinion. The patient self-referred for an assessment.
Upon investigation, the patient was found to have invasive cervical resorption affecting the central incisor, which is an inflammatory process that destroys tooth structure. It had caused a subgingival defect on the buccal surface of the tooth. A 3D X-ray was taken to assess the size of the lesion and its impact on the pulp – necrosis of the tissue was detected on the CBCT image, from which we could also identify the odd shape of the defect.
All possible treatment options were discussed thoroughly with the patient. These included tooth extraction and a denture, or root canal treatment and surgical repair of the defect. The patient was keen to save the tooth if at all possible. The risks and potential limitations of this treatment were explored in detail. For an anterior veneer like this, aesthetics would be an important element. As the defect was on the buccal surface of the root, the primary risk would be recession – the patient was happy to accept these possibilities and was willing to proceed with a new veneer if it became a problem.
During the treatment appointment, both root canal therapy and the surgical procedures were performed. An incision was made in the gingiva to fully expose the defect – which extended into the root canal system – to allow for adequate cleaning. A common issue with this type of treatment is that repairing the defect there and then can result in blocking of the canal. To avoid this, a conventional endodontic access to the canal was achieved and a gutta percha point was placed in the canal while the defect was repaired and removed after the material had set to prevent any blockages. The resorption defect was restored using glass ionomer. The gingivae were then sutured closed using 5/0 vicryl rapide sutures and then a standard root canal treatment was performed.
A rubber dam was applied to achieve airway protection and effective moisture control. The appropriate working length was established using an apex locator. An F4 ProTaper file (Dentsply) was used to prepare the canal, along with a 5.25% sodium hypochlorite (NaOCl) solution to irrigate. After canal preparation was completed, a 17% EDTA solution was used to remove the smear layer. The canal was then further disinfected employing the IHAN (intracanal heating and ultrasonic agitation of NaOCl) technique. Small heated plugger tips (Eighteeth Medical Fast Pack Tips) were used to heat the solution in the canal, with 10 seconds of heating followed by 10 seconds of passive ultrasonic activation using irrisafe instruments. This cycle was repeated five times in total with fresh NaOCl. Obturation was achieved with a vertical compaction technique. The endodontic access cavity was restored using SDR composite (Dentsply). The occlusion was checked upon completion and the restoration polished and finished.
The patient returned to the practice for review about six months later. Everything had healed well and the soft tissue was healthy. Only very minor gingival recession had occurred so the patient was very happy with the aesthetic outcome.
This case demonstrates clearly the importance of exploring all potential options before turning to extraction. Many GDPs will believe a tooth to be unrestorable when in fact there are still some solutions that could be tried – even if the tooth is only saved for another few years, it is often still worth it. I think it’s essential for GDPs to be aware of the occurrence of resorption defects and how they present. There is commonly a small pink defect in the gum, which can be an indication of resorption defect with hyperplastic gingival tissue at the margin. Dentine, if you probe with a sharp instrument, is hard and so a dentine crater will be hard. Decay is only indicated if the material is soft upon probing.
A CBCT is also clinically useful in these cases to identify the location and size of the defects. If a GDP was very confident in endodontics and oral surgery and thinking of managing these cases themselves, it is crucial to obtain a CBCT scan first. As a fairly complex area of dentistry, most GDPs would likely be uncomfortable with the surgical aspects of treatment and would need to refer.
Images
Figure 1 – Photo taken after anaesthetic administered
Figure 2 – pre-operative periapical radiograph
Figure 3 – CBCT images
Figure 4 – resorption defect cleared, gutta percha cone visible in canal
Figure 5- post-operative periapical radiograph
Figure 6 – 6 month review
Figure 7 – 6 month review radiograph showing apical healing
For more information about Dr Currie or Lodge Dental, or to refer a patient, please visit www.lodgedental.co.uk
Author:
Dr Cameron Currie graduated from Bristol Dental School in 2007, before completing further training and becoming a Member of the Faculty of Dental Surgeons (RCS[Ed]) in 2011. He went on to undertake a Diploma in Endodontic Sciences at the world-renowned UCL Eastman Dental Institute and completed a MSc in Endodontics at the University of South Wales. He currently limits his practice to endodontics and is an active member of the BES, ESE and AAE.
