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