A combined surgical and non-surgical approach to repair an external root resorption utilizing a nano-particulate bioceramic root repair material

141116 Nasseh FeatureDr. Allen Ali Nasseh illustrates a case report for non-surgical root canal treatment and the surgical repair of an extensive external root resorption defect


The applications of bioceramic compounds in endodontic therapy range all the way from their non-surgical use as a root canal sealer, a pulp capping agent, and a perforation repair material to their surgical applications for root repair and apiecoectomy procedures.

The first bioceramic compound introduced, MTA (DENTSPLY Tulsa), was derived from Portland cement and has proven to be a valuable root repair material for surgical applications.1-3 More recently, medically pure nano-particulate bioceramic formulations (that have been engineered from the ground up) have improved on some notable shortcomings of MTA by addressing the clinical handling challenges associated with this first-generation material.4-15 In addition, the removal of heavy metals that can cause tooth staining in MTA-repaired cases has also been addressed with these newer second-generation formulations. 141116 Nasseh 01

This new family of compounds, known as EndoSequence® BC Sealer™, Root Repair Material (RRM™), and Fast Set Putty (Brasseler USA®), has shown significant clinical handling advantages over MTA for both non-surgical and surgical applications. Due to their nano-particulate size and viscosity, these materials can now be used as a sealer and/or filler for root canal obturation, as well as for the surgical repair of root defects and apicoectomies.

This clinical case report demonstrates the use of EndoSequence bioceramic formulations  for both the non-surgical root canal treatment and the surgical repair of an extensive external root resorption defect in a single central incisor.

Case report

A 26-year-old female presented with a chief complaint of discomfort and swelling around her front tooth (Figure 1). She explained that she was seeking a third opinion after being told twice that tooth No. 9 was not salvageable and had to be extracted. Clinical testing and evaluation revealed erythematous gingival tissues on the buccal aspect of tooth No. 9 with deep probing (+6 mm with BOP on the buccal and normal probing on the lingual). Testing also revealed that all anterior teeth were within normal limits to thermal and percussion test except for tooth No. 9, which was positive to percussion with severe and lingering response to cold. Upon radiographic examination, tooth No. 9 was diagnosed with extensive external root resorption. A history of protracted orthodontic therapy 10 years ago was noted in the patient’s dental history. A pulpal diagnosis of symptomatic irreversible pulpitis was made, and the prognosis, given the large extent of the resorptive defect, was deemed guarded to questionable at best. Extraction was deemed the most predictable option. The patient, however, was very motivated and wanted to attempt to save her tooth despite the guarded prognosis. 141116 Nasseh 02141116 Nasseh 03141116 Nasseh 04

The non-surgical endodontic therapy was completed in a single visit using a combination of EndoSequence Root Repair Material (RRM) Putty in a barrier technique and EndoSequence Root Repair Material (RRM) syringeable formulation (Brasseler USA) to fill the entire canal in the following manner.

Following cleaning and shaping to a size 70/.04 EndoSequence File (Brasseler USA), the tooth was further disinfected with full-strength (7%) sodium hypochlorite. This was accomplished by using a negative irrigation system (EndoVac® MacroCannula) (SybronEndo) and a Forza V3 ultrasonic unit with an E11 tip/size 20 U-blade insert (Brasseler USA). Thereafter, a size 70/.04 EndoSequence BC gutta-percha cone (Brasseler USA) was fitted to the apex with tug back. The cone was then trimmed with a scalpel blade so that it would fit 4 mm short of the apex. A 4-mm plug of EndoSequence BC Putty was then condensed to the apex using the fitted cone so that a 4-mm plug of putty filled the apex, creating a barrier (Figure 2). The apical barrier technique has been described previously.16,17 The cone was then removed, and the entire remaining canal was filled with syringeable BC-RRM. The access was restored with Fuji IX (Figure 3). The patient was rescheduled for surgical repair of the external defect 2 weeks later. The surgical appointment was not scheduled concurrently in order to allow time for the intraradicular cement to set and to evaluate patient response.

The patient returned for the surgical root repair visit, and a sinus tract was noted on the buccal aspect of the tooth presurgically (Figure 4). A large external resorption defect was noted on the buccal aspect of the root after a full thickness intrasulcular flap was raised (Figure 5). Using a high-speed round bur and copious amounts of water, the defect was prepared, and all visible resorptive soft tissue in the root was drilled out until the root canal was reached, exposing the set EndoSequence RRM material inside the root canal (Figure 6). Once all the soft tissue was removed, the remaining preparation and the exposed root surfaces were conditioned with citric acid. The remaining root defect was then repaired with an equivalent amount of bioceramic putty trying to keep the natural curvature of the root (Figure 7), and the flap was sutured closed.141116 Nasseh 05

The immediate postoperative radiographs show the extent of the root repair with the putty in this tooth (Figure 8). Following normal postoperative healing, the patient was evaluated at 6 months and 2 years, where the gingival tissue was observed to be fully healed, and probing was found to be within normal limits (Figure 9). At this point, the surgical repair procedure was deemed successful. The postoperative esthetics were completely acceptable to the patient, and no tooth staining was noted as a result of the material used to repair this tooth internally or externally.


Extensive external root resorption and other aggressive forms of cervical root resorption are challenging when they cause significant root damage. These lesions can sometimes be monitored requiring no intervention at all. However, when endo-perio involvement results in pulpitis, and later infection of the resorption defect, extraction of the tooth or surgical repair of the root are the only viable options. In cases where direct surgical access with good visualization of the defect can be achieved, the use of modern bioceramic formulations (which are easy to apply to the site and have demonstrated excellent biocompatibility, bonding, and hydrophilic qualities) may be an excellent clinical choice. In this clinical case, the use of nano-particulate premixed bioceramic formulations, both EndoSequence syringeable BC Root Repair Material (RRM) and putty were demonstrated. Long-term follow-up of the healing of the gingival tissues and acceptable esthetics were achieved in a tooth that was otherwise deemed unsalvageable. The ease of clinical handling during surgery and a lack of dentin staining were noted. Further studies in this area are warranted in order to explore the true potential of this family of compounds in root repair applications, as well as all other aspects of endodontic therapy, where direct contact between biological tissues and biocompatible repair material is essential to success.


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