JICDRO is a UGC approved journal (Journal no. 63927)

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CASE REPORT
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 97-100

Rootless existence: A case report of internal resorption


Department of Oral and Maxillofacial Surgery, Sinhgad Dental College and Hospital, Pune, Maharashtra, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Shrikant Subhash Dusane
4, Gulabpushpa Building, Opp. Paramount Garden, Kondwa Road, Katraj, Pune - 411 046, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_6_18

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   Abstract 


Internal resorption is a relatively rare resorption of dentine, which starts in the pulpal cavity either in the pulpal chamber or in the root canal and destroys surrounding dental hard tissues. The initiating factor in internal root resorption is thought to be trauma or chronic pulpal inflammation, but other etiological factors have also been suggested. In this article, we report a rare case of complete root resorption of maxillary anteriors in a 23-year-old female patient.

Keywords: Avulsion, external resorption inflammatory, internal resorption


How to cite this article:
Dusane SS, Raikwar KR, Bhagat BR, Suryavanshi RK. Rootless existence: A case report of internal resorption. J Int Clin Dent Res Organ 2018;10:97-100

How to cite this URL:
Dusane SS, Raikwar KR, Bhagat BR, Suryavanshi RK. Rootless existence: A case report of internal resorption. J Int Clin Dent Res Organ [serial online] 2018 [cited 2019 Mar 21];10:97-100. Available from: http://www.jicdro.org/text.asp?2018/10/2/97/249140




   Introduction Top


Resorption is defined as a condition associated with either a physiologic or a pathologic process resulting in loss of dentin, cementum, or bone. Andreasen has classified tooth resorption as internal (inflammatory and replacement) and external (surface, inflammatory, and replacement).[1] The internal resorption is also called intracanal resorption. It is considered as a rare case of resorption which appears as a typical dystrophy of the pulp which jeopardizes the hard tissue of the teeth, thus changing its normal morphology. Root resorption is the loss of dental hard tissues as a result of clastic activities. It might occur as a physiological or pathological phenomenon. Root resorption in the primary dentition is a normal physiological process except when the resorption occurs prematurely. The initiating factors involved in physiological root resorption in the primary dentition are not completely understood, although the process appears to be regulated by cytokines and transcription factors that are similar to those involved in bone remodeling. Unlike bone that undergoes continuous physiological remodeling throughout life, root resorption of permanent teeth does not occur naturally and is invariably inflammatory in nature. Thus, root resorption in the permanent dentition is a pathological event; if untreated, this might result in the premature loss of the affected teeth.[2] It is caused by transformation of normal pulp tissue into granulomatous tissue with giant cells, which resorb dentine. Trauma, caries, and restorative procedures have been suggested to be contributing factors, but it also occurs as idiopathic dystrophic changes. Most cases of internal resorption are asymptomatic and often detected as an incidental radiographic finding. When internal resorption is detected, root canal therapy is the only effective treatment and should begin as soon as possible to limit progression.


   Case Report Top


A 23-year-old female patient came to the Department of Oral and Maxillofacial Surgery of with a complaint of mobility in the upper anterior prosthesis [Figure 1] for 2–3 months which had noticeably increased in the past 8–10 days.
Figure 1: intraoral photograph of the patient with mobile maxillary right anterior prosthesis

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The patient gave a history of trauma to the upper anteriors 5 years back with avulsion of the right maxillary central and lateral incisors along with canine. The patient also gives a history of reimplantation of all avulsed teeth followed by root canal treatment and porcelain-fused-to-metal crowns with maxillary central incisor, lateral incisor, and canine 5 years back at the Endodontic Department in our college. The patient gave no relevant medical history.

On examination, right maxillary central incisor, lateral incisor, and canine had porcelain-fused-to-metal crowns. Grade II mobility was seen with maxillary central and lateral incisors and Grade I mobility with canine. Intraoral periapical radiographs of the maxillary right anterior region revealed missing 11 and 12 with two linear radiopacities indicative of gutta-percha cones surrounded by healthy bone, existing without roots in 11 and 12 regions, respectively. 13 radiographically was endodontically treated and showed expanded boundary limits of the pulp with very mild irregular contours except in the apical third region with perforation on the mesial surface of the root. There were no evidence of infection radiographically [Figure 2] and [Figure 3]. Periapical radiograph findings were confirmed on cone-beam computed tomography (CT) scan to rule out any possible evidence of root left in the maxillary 11 and 12 regions. Treatment plan decided comprised extraction of 11, 12, and 13 with removal of gutta-percha points followed by prosthetic rehabilitation. However, as canine was more firm as compared to 11 and 12, the patient was not willing for extraction of 13. Therefore, extractions were done with 11 and 12 with removal of gutta-percha points [Figure 4] and [Figure 5], and the patient was recalled for extraction of 13 at a later date. However, the patient did not follow-up after that.
Figure 2: intraoral periapical radiographs revealing missing 11 and 12 with two linear radiopacities indicative of gutta-percha cones surrounded by healthy bone, existing without roots in 11 and 12 regions respectively

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Figure 3: intraoral periapical radiographs showing endodontically treated 13 with expanded boundary limits of the pulp and very mild irregular contours with perforation on the mesial surface of the root except in the apical third region

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Figure 4: extracted crowns of 11 and 12 with gutta-percha points

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Figure 5: intraoral photograph after extraction

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   Discussion Top


Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis. Reimplantation is the treatment of choice in most situations but cannot always be carried out immediately. Reimplantation may successfully save the tooth, but it is important to realize that reimplanted teeth have lower chances of long-term survival rate and may even be lost or extracted at later date.

External resorption begins from the external or cervical surface of the tooth and proceeds inwards and is associated with factors such as periapical pathosis, pressure from orthodontic treatment, and rapidly growing tumors. Internal resorption can be categorized by the type/cause of resorption as inflammatory, transient, progressive, and replacement.[3] Inflammatory resorption is more likely to commence following damage to the predentin subsequent to a bacterial infection or trauma. A transient internal resorption is another form of trauma-induced, noninfective, self-limiting root resorption and this will generally follow a luxation injury.[4] Progressive type of internal resorption is stimulated by constant inflammation following infection.[5] It has been documented that the process is initiated by a variety of stimuli such as trauma, pulpotomy, extreme heat produced during cutting of dentin, chronic inflammation of the pulp following caries perpetuated by bacterial factors, cracked tooth, tooth transplantation, and orthodontic treatment.[6],[7]

In our case, the patient gave a history of avulsed 11, 12, and 13 for which endodontic treatment was done along with replantation as per accepted replantation protocol described by the International Association of Dental Traumatology[8] as there might have been no chances of obtaining pulp space revascularization and the periodontal ligament would have been necrotic and not expected to heal.

In our case, the teeth were already endodontically treated before the clinical and radiological commencement of internal resorption at the time of reimplantation. Diagnosis of internal root resorption was made with 11 and 12 was made because 13 radiographically showed expanded boundary limits of the pulp with mild irregular contours except in the apical third region with perforation on the mesial surface of the root. However, if even the canine showed complete root resorption with no evidence of root at all, coming to diagnosis regarding the type of the root resorption, whether external or internal would have been very difficult. The active and ongoing process of internal resorption of 23 was, therefore, an important deciding factor for the diagnosis.

When resorption has progressed to involve an external communication, the tooth cannot be retained in most cases. In our case, there was complete resorption with no evidence of root with 11 and 12, and therefore, the crowns were extracted. Cone-beam CT scan was of great help to rule out any evidence of root.

Conventional root canal therapy results in a high degree of success in the treatment of nonperforating internal resorption.[9],[10] Delayed treatment can lead to progressive internal resorption. However, it can be arrested in its initial phase if detected earlier. Root canal therapy interrupts with the resorptive process. The prognosis of treatment depends on the extent or the size of lesion. When internal resorption is clinically detected, pulpectomy is needed to arrest the resorption. Or if the tooth is already endodontically treated requires a repeat of endodontic treatment to completely remove the vital pulp tissue left behind during previous treatment to achieve pulpectomy and ultimately to stop the progression of internal resorption which was not possible in our case due to lack of follow-up.

This case report of internal root resorption is aimed to stress importance of follow-up of patients after dental trauma. This case report also throws light that internal resorption can still continue after root canal treatment due to incomplete removal of vital pulp, and hence, complete pulp removal should be given prime importance which is the basic aim of endodontic treatment. Reimplanted teeth should be monitored by clinical and radiologic control after 4 weeks, 3 months, 6 months, 1 year, and yearly thereafter for early diagnosis and appropriate choice of endodontic treatment.

Cases of internal resorption are not uncommon, but this case becomes unique showing complete root resorption with dormant gutta-percha enhancing and highlighting the process of internal resorption.


   Conclusion Top


After dental traumas, sequelae such as root resorption, root canal obliteration, interruption in root formation, periapical lesion, and damages to permanent tooth buds are frequently observed in patient's follow-up appointments. Early diagnosis, removal of the cause, and proper treatment of the resorbed root are mandatory for successful treatment outcome. Therefore, follow-up radiographic examination of traumatized teeth plays an important role in the early diagnosis of these alterations. Cases of internal resorption are not uncommon, but this case becomes unique showing complete root resorption with dormant gutta-percha enhancing and highlighting the process of internal resorption in its own way.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Andreasen FM, Andreasen JO. Resorption and mineralization processes following root fracture of permanent incisors. Endod Dent Traumatol 1988;4:202-14.  Back to cited text no. 1
    
2.
Fernandes M, Ataide ID, Wagle R. Tooth resorption part 1 – Pathogenesis and case series of internal resorption. J Conser Dent 2013;2013:4-8.  Back to cited text no. 2
    
3.
Ne RF, Witherspoon DE, Gutmann JL. Tooth resorption. Quintessence Int 1999;30:9-25.  Back to cited text no. 3
    
4.
Andreasen FM. Transient apical breakdown and its relation to color and sensibility changes after luxation injuries to teeth. Endod Dent Traumatol 1986;2:9-19.  Back to cited text no. 4
    
5.
Holmes JP, Gulabivala K, van der Stelt PF. Detection of simulated internal tooth resorption using conventional radiography and subtraction imaging. Dentomaxillofac Radiol 2001;30:249-54.  Back to cited text no. 5
    
6.
Trope M. Root resorption due to dental trauma. Endod Top 2002;1:79-100.  Back to cited text no. 6
    
7.
Solomon CS, Coffiner MO, Chalfin HE. Herpes zoster revisited: Implicated in root resorption. J Endod 1986;12:210-3.  Back to cited text no. 7
    
8.
Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ, et al. International Association of Dental Traumatology Guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol 2012;28:88-96.  Back to cited text no. 8
    
9.
Morse DR. Internal root resorption obturated by the gutta-percha-eucapercha endodontic method: Report of a case. Compend Contin Educ Dent 1985;6:414-7, 420-3.  Back to cited text no. 9
    
10.
Samimy B. Idiopathic internal root resorption – A case report. J Br Endod Soc 1978;11:11-2.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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