Management of a tooth with a large internal resorption defect

Dr. Robert Slosberg’s patient returns to the office for her 18-month follow-up appointment

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Abstract
A patient presented with advanced internal root resorption of tooth No. 9. The prominent location of this tooth meant the case would be a challenge from an esthetic standpoint; an implant-supported crown would have been cost-prohibitive, and veneers would have been necessary to give the patient satisfactory cosmetic results. This option required too much of a cost and time commitment from the patient.

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The initial treatment plan included filling the tooth with an orthodontic-grade root filling material to be followed by surgery. Visualization from a cone beam computed tomography (CBCT) scan provided accurate mapping of the defect, revealing the apical lingual perforation. Postoperatively, the CBCT scan confirmed the successful permeation of the filling material.

This case could not have been treated successfully without the use of the CBCT, both pre- and postoperatively. Placing the medication to obturate the tooth was difficult, yet the CBCT scans provided guidance allowing for measurement of the progress throughout the case. Dental radiographs offer only a 2D representation of the 3D spatial relationship, while CBCT scans allow the clinician to see every angle of a case before they even begin to operate.

Introduction
A healthy, asymptomatic 50-year-old female presented at my office in the spring of 2014, having been referred by her general practitioner. A resorption defect had been discovered during a routine periapical examination of tooth No. 9.

Because of the prominent location, it was clear from an esthetic standpoint that it would be a challenge to replace the tooth. In fact, treatment options were heavily influenced by both esthetics and the finances of the patient. An implant-supported crown and veneers may not have given the patient a satisfactory esthetic result. Additionally, such extensive work would have required a greater financial commitment from the patient.

The initial treatment plan was to fill the tooth with a conventional orthodontic-grade root filling material to be most likely followed by surgical debridement; at the time, it seemed that surgery was indeed the only option. However, as we would discover, CBCT technology provided accurate mapping and obturation of the defect, eliminating the need for surgery, at least for now.

(top row) Figure 1: Pre-op clinical image; Figure 2: Pre-op clinical image showing labial positioning (bottom) Figure 3A: Pre-op radiograph 2-3-2014; Figure 3B: Off angle radiograph 2-3-2014
(top row) Figure 1: Pre-op clinical image; Figure 2: Pre-op clinical image showing labial positioning (bottom) Figure 3A: Pre-op radiograph 2-3-2014; Figure 3B: Off angle radiograph 2-3-2014
Figure 4: Pre-op sagittal slice; Figure 5: Pre-op axial slices Figure 6: Pre-op coronal slice
Figure 4: Pre-op sagittal slice; Figure 5: Pre-op axial slices Figure 6: Pre-op coronal slice
Figure 7: Measuring the defect; Figure 8: Initial access; Figure 9: Working length determination
Figure 7: Measuring the defect; Figure 8: Initial access; Figure 9: Working length determination
Figure 10: Ca(OH)2 PA; Figure 11: Ca(OH)2 sagittal slice; Figure 12: Clinical image temporization
Figure 10: Ca(OH)2 PA; Figure 11: Ca(OH)2 sagittal slice; Figure 12: Clinical image temporization
Figure 13: Clinical access enlargement; Figure 14: Clinical image extension of access opening to facilitate obturation; Figure 15: Clinical image obturation with bioceramic putty; Figure 16: EndoSequence BC RRM Putty
Figure 13: Clinical access enlargement; Figure 14: Clinical image extension of access opening to facilitate obturation; Figure 15: Clinical image obturation with bioceramic putty; Figure 16: EndoSequence BC RRM Putty

Clinical and radiographic examination
The resorptive defect — the patho-logical process in which the tooth begins to dissolve — was initially diagnosed by radiograph; however, the CBCT scan showed the exact extent of the defect, as well as revealed an apical lingual perforation, which presented yet another challenge.

  • Medical history: Non-contributory
  • Diagnosis: Advanced internal root resorption
  • Immediate treatment plan:  Canal obturation and filling

Treatment
A coronal access opening was made, and the tooth was packed with calcium hydroxide. This proved challenging as controlling placement of the calcium hydroxide was particularly difficult. A temporary filling was then placed, and the medication was changed over the course of 2 to 3 months. CBCT scans were taken postoperatively to determine where the medication was and where it wasn’t. On the advice of a colleague, the access opening was extended toward the lingual to facilitate the vertical condensation of the root filling material — in this case, Brasseler bioceramic mineral trioxide aggregate (MTA) cement. On top of the EndoSequence® BC RRM™ (Root Repair Material) and EndoSequence® BC Sealer™, a composite resin core buildup of exactly 10 mm deep was placed.

Figure 17: Post-op radiograph; Figure 18: Post-op axial slices; Figure 19: Post-op axial slice; Figure 20: Post-op sagittal slice
Figure 17: Post-op radiograph; Figure 18: Post-op axial slices; Figure 19: Post-op axial slice; Figure 20: Post-op sagittal slice
Figure 21: Post-op coronal slice; Figure 22: Post-op clinical image composite restoration; Figure 23: Post-op clinical image; Figure 24: Measuring the depth of the composite resin
Figure 21: Post-op coronal slice; Figure 22: Post-op clinical image composite restoration; Figure 23: Post-op clinical image; Figure 24: Measuring the depth of the composite resin
Figure 25: 4-30-2014 re-evaluation; Figure 26: 4-30-2014 re-evaluation
Figure 25: 4-30-2014 re-evaluation; Figure 26: 4-30-2014 re-evaluation

Results
CBCT scans allowed for accurate mapping of the defect, and they were the only way to assess the effective permeation of the bioceramic putty.

Discussion
Due to the many challenges this case presented, the mapping of the defect was shared among endodontic professionals — trusted colleagues, local study clubs, and endodontic online forums. The majority of the dental professionals recommended extraction and an implant-supported crown.

Esthetics and finances directed this individualized treatment plan. Filling the tooth — even if it were maintained for up to 5 years — would allow the patient time to save enough money for an implant-supported crown. For ideal esthetics with an implant-supported crown, at least one or more veneers would most likely be necessary; therefore, a steep financial and time commitment would be required from the patient.  Surgery was always an option, depending on the outcome of endodontic therapy.

This case could not have been treated successfully without the use of CBCT scans. In fact, the patient was referred specifically to our practice because we are known for our use of CBCT technology. CBCT gives us additional information that conventional 2D radiographs cannot. In this case, it facilitated both accurate mapping and obturation of the resportive defect. The scans can answer important questions such as “Can the defect be reached?” Once completed, CBCT answers, “How adequately was the tooth sealed?”

In this particular case, CBCT scans were crucial in confirming the placement of the calcium hydroxide and the bioceramic resin. Placing the medication was a challenge, and CBCT scans measured the progress throughout the case. A CBCT scan can also be a professional’s worst critic. The scan will reveal, “You didn’t get the calcium, medication, or filling material here.” In conclusion, it was a CBCT scan that confirmed the successful condensation of the bioceramic putty used to seal the tooth, and surgery was avoided, at least, in the short term. The patient is asymptomatic and is due for a recall.

In the modern endodontic office, CBCT is a powerful new tool to aid in the diagnosis and treatment of diseases involving the teeth and supporting structures. Dental radiographs can only offer a 2D representation of the 3D spatial relationship. However, today’s specialists can understand that spatial relationship better with the advent of CBCT.

Following a detailed clinical evaluation, including radiographs, it may be necessary to gain more information — information that only CBCT scans can provide. CBCT technology provides a complete visual image covering the axial, coronal, and sagittal planes. Additionally, the 3D rendering is also an excellent tool for patient education and can lead to increased case acceptance.

The advent of CBCT and its subsequent introduction into the endodontic specialty have been a paradigm shift. The more scans I have reviewed, the more I realize just how important a 3D scan can be to comprehensive diagnosis; at this point, CBCT scans are taken for most of my endodontic cases, as they can solve the mysteries that are left uncovered by 2D radiography.

Returning to the case at hand: “If it were your patient, what would you recommend? Even more importantly, if it were your tooth, how would you want it treated?”
Lessons learned

  • Extending the access opening lingually was not ideal, though it was necessary to adequately condense the bioceramic putty.
  • In hindsight, the tooth could have been strengthened had a fiber post been placed along with composite resin.
  • Recent technological advancements in Endodontics have made treatment options possible, that were not available just a few years ago.

18-month recall
At an 18-month recall appointment, the patient has remained asymptomatic. Clinically, probing depths were WNL, and the tooth has remained esthetically pleasing. On the new cone beam, the periapical area, as well as the lateral aspect of the sealed defect, is suggestive of periapical healing. No new defects were noted internally. The patient was dismissed and placed on a 1-year recall.

A closer look at the CBCT scan, however, is suggestive of a resorptive defect on the buccal surface, approximately 11 mm from the incisal edge. What would you do next?

Top row: Figure 27: Follow-up radiograph; Figure 28: Follow-up radiograph. Bottom row: Figure 29: Microscope follow-up image; Figure 30: Follow-up image
Top row: Figure 27: Follow-up radiograph; Figure 28: Follow-up radiograph. Bottom row: Figure 29: Microscope follow-up image; Figure 30: Follow-up image
Figure 31: Follow-up axial slices; Figure 32: Follow-up coronal slice; Figure 33: Follow-up sagittal measurement
Figure 31: Follow-up axial slices; Figure 32: Follow-up coronal slice; Figure 33: Follow-up sagittal measurement

Figure 34: Follow-up axial slices; Figure 35: Sagittal resorption defect; Figure 36: Axial resorption defect
Figure 34: Follow-up axial slices; Figure 35: Sagittal resorption defect; Figure 36: Axial resorption defect

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