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Internal Root Resorption Repair With A Bioceramic Sealed Endodontic Stabilizer
A Case Report IUSD Department of Graduate Endodontics
B. J. BRASSEALE*, K. J. SPOLNIK, M. M. VAIL
Introduction Internal Root Resorption (IRR) is an inflammatory phenomenon that employs native
odontoclasts to resorb intraradicular dentin by a mechanism similar to bone resorption.1 In
deciduous teeth, this clastic activity is adaptive and allows for the timely exfoliation of the
primary tooth crown. However, in permanent teeth the progressive erosion of intraradicular
dentin is a pathologic process that can results in loss of root strength and eventual tooth loss
if not intercepted by the Dentist. 2
IRR is a rare clinical entity. It is more common in men than in women, involving the
maxillary incisor most frequently and is often associated with a history of trauma to the area.
IRR progresses asymptomatically in its early stages at which time it is only detectable by
radiography. It is often only after root perforation and subsequent bacterial infection that the
first clinical signs become evident. Patients will describe symptoms of acute odontogenic
infection including pain, tenderness to percussion, tenderness to palpation, mobility,
swelling, or drainage. By the time these signs and symptoms are present, resolution of the
pathosis by routine endodontic treatment is often impossible.3 The following case report
outlines a novel therapeutic approach for treating cases of severe internal resorption.
Initial Exam 4/21/2010
A 56-year-old male was referred to the IUSD Graduate Endodontic clinic for evaluation of
tooth #9. The patient reported a 1-year history of periodic swelling, drainage and mild pain in
the labial attached gingival adjacent to tooth #9. The patient’s medical history was
noncontributory. The patient stated that he had been instructed by his dentist to have tooth
#9 extracted a year prior, but refused to comply and was emphatic that he wanted to save his
tooth if at all possible. The extraoral exam was unremarkable. The intraoral exam revealed
an unrestored tooth #9, Class I mobility, periodontal probing depths <3mm, and a small, 2
mm sinus tract in the labial gingiva at the midroot level of tooth #9. Radiographic exam
showed a 4 mm x 5 mm midroot radiolucency, obscuring the canal space, with lateral root
radiolucency (Fig. 1). A Cone Beam Computed Tomography (CBCT) was obtained to
determine the extent of the resorptive destruction and the position of the tooth in the alveolus
(Fig. 2 & 3). The CBCT clearly shows a midroot perforation.
The patient was informed of the presence of the internal resorption and associated
perforation, and advised that nonsurgical endodontic treatment and traditional surgical
perforation repair was not indicated due to the extent of the resorption. The patient was
advised that the most predictable treatment option would be the extraction of tooth #9 with
placement of an endosseous implant. At this suggestion, the patient was emotionally
distraught and asked , “Isn’t there anything we can do to keep this tooth?” The suggestion
was made to surgically resect the portion of the root apical to the resorptive defect, and then
compensate for the resultant poor crown:root ratio by placing an endodontic stabilizer. The
patient reviewed and signed the informed consent and scheduled for surgical root resection
with an endodontic stabilizer.
Surgical Root Resection with Endodontic Stabilizer 6/28/2010
The patient was sedated at the time of treatment with 0.25 mg triazolam and 10 mg diazepam
administered orally. Blood pressure, oxygen saturation, and pulse were monitored
throughout appointment. Profound anesthetic was achieved with the use of 68 mg lidocaine
with 0.034 mg epinephrine and 9 mg bupivacaine with 0.009 mg epinephrine administered as
buccal and palatal supraperiosteal infilatrations adjacent to teeth #6-11. A 0.12%
chlorohexidine gluconate swab of the surgical site was completed.
Surgical Root Resection with Endodontic Stabilizer (continued) 6/28/2010
Rubber dam isolation of tooth #9 was completed. Non-surgical debridement of the root
canal space was completed to the level of the resorptive defect as determined with
radiographs and an electronic apex locator. Instrumentation was completed to a sufficient
diameter to accommodate the endodontic stabilizer. Irrigation of the root canal space was
accomplished using 2.0% chlorohexidine gluconate and sterile saline. After the
completion of non-surgical root canal debridement, a full-thickness mucoperiosteal flap
with vertical releasing incisions was raised from the distal of tooth #8 to distal of tooth #10.
Upon reflection of the surgical flap, a 3 mm round, granulation tissue filled fenestration of
the labial cortical plate was observed over the midroot of tooth #9. A straight surgical
handpiece with sterile saline irrigation was used to enlarge the osteotomy. Granulation
tissue was curetted from the surgical crypt, and the portion of the root apical to the
resorptive defect was resected. Preparation of the canal space and alveolar bone was
completed with endodontic stabilizer preparation drill at slow speed with sterile saline
irrigation. The endodontic stabilizer was then trial-fit in the prepared canal and osteotomy
prior to cementation and grafting (Fig.4). A radiograph was taken to ensure proper
endodontic stabilizer positioning. The endodontic stabilizer was then trimmed to length
and cemented into canal space with a bonded composite resin and sealed with
EndoSequence Root Repair Material bioceramic putty. Bone grafting of surgical crypt was
completed with demineralized freeze dried bone and covered with a dynamatrix membrane
(Fig. 5). The flap was then replaced and sutured, and a post-op radiograph was taken (Fig.
6). The patient returned to clinic 4 days later for suture removal. At suture removal
appointment, healing was uneventful, sutures were removed, and patient was
asymptomatic. A three month post-operative appointment was scheduled.
6 Month Post-Operative Evaluation 12/21/2010
The patient presented for a 3-month postoperative exam of tooth #9. The patient was
extremely pleased with the outcome of the surgery, stating, “It’s perfect.” Radiographic
examination showed no development of radiolucency at graft/stabilizer site (Fig. 7).
Examination of the periodontium showed normal gingival architecture with no signs of
inflammation, no swelling, and no sinus tract. Probing depths were <3 mm, and tooth #9
was stable with no mobility (Fig. 8). The patient was informed that he is healing without
complications and to return in 3 more months for post-op evaluation.
Discussion
Endodontic stabilizers are valuable clinical adjuncts that enable the endodontics to save
teeth that would have had compromised crown to root ratios otherwise.4 Some early
endodontic stabilizers made from vitalium received criticism for being prone to corrosion
and crown-down leakage.5 Long-term clinical success of stabilizers made from titanium
that are not prone to corrosion have been reported, but this case study is the first to show
the use of a titanium stabilizer sealed with bioceramics.6 This case study indicates that with
improvement in materials, endodontic stabilizers can be a valuable adjunct in modern
conservative restorative dentistry.
References
1.Patel S, Ricucci D, Durak C, Tay F. Internal root resorption: a review. J Endod
2010;36:1107-21.
2. Tronstad L. Root resorption – etiology, terminology and clinical manifestations. Dent
Traum 1988;4:241-52.
3. Johnson BR FM, Witherspoon DE. Pathways of the Pulp. 10th ed. St. Louis: Mosby; 2011
4.Simon JH, Frank AL. The endodontic stabilizer: additional histologic
evaluation. J Endod 1980;6:450-5.
5.Ferguson A, Laing P, Hodge E. The ionization of metal implants in living
tissues. J Bone Joint Surg [Am] 1960;42A:77-90.
6.Feldman M, Feldman G. Endodontic Stabilizers. 1992;18:245-8.
Figure 1: #9 Periapical Pre-Op Figure 2: CBCT Sagittal Slice Figure 3: CBCT Axial Slice
Figure 4: Endodontic Stabilizer Placement Figure 5: Graft with Membrane
Figure 6: Post-Op Figure 7: 6-Month Recall
Figure 8: 3-month post-op