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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 1  |  Page : 125-128

Invasive cervical resorption: An endodontic challenge managed by intentional replantation

Department of Conservative Dentistry and Endodontics, Government Dental College and Hospital, Ahmedabad, Gujarat, India

Date of Web Publication19-Jun-2019

Correspondence Address:
Dr. Madhu Ahra
B-901, Gurukul Park, Near Sterling Hospital, Gurukul Road, Memnagar, Ahmedabad - 380 052, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/endo.endo_64_18

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Invasive cervical resorption (ICR) is an aggressive form of tooth resorption that is not well understood. Accurate diagnosis and early management are prerequisites for long-term retention of the tooth. Treatment procedure includes eliminating the resorptive tissue followed by restoring the defect with a suitable biocompatible material. This case report is on successful management of an ICR lesion; inaccessible to the conventional procedure; by root canal treatment and intentional replantation (IR) of the tooth for complete debridement and sealing of resorptive site with biodentine. At 18-month recall, the tooth was clinically sound with no radiographic evidence of inflammatory or replacement root resorption. Thus, IR should be considered as a viable treatment option.

Keywords: Biodentine, intentional replantation, invasive cervical resorption

How to cite this article:
Ahra M, Abuwala T, Parmar G. Invasive cervical resorption: An endodontic challenge managed by intentional replantation. Endodontology 2019;31:125-8

How to cite this URL:
Ahra M, Abuwala T, Parmar G. Invasive cervical resorption: An endodontic challenge managed by intentional replantation. Endodontology [serial online] 2019 [cited 2020 Jan 27];31:125-8. Available from: http://www.endodontologyonweb.org/text.asp?2019/31/1/125/260532

  Introduction Top

Invasive cervical resorption (ICR) is uncommon and often aggressive form of external tooth resorption. It is defined as a localized resorptive process that involves the surface of root below epithelial attachment and coronal aspect of the supporting alveolar process, namely the zone of connective tissue attachment.[1] It is hypothesized to result from a deficiency or damage to the protective cementum immediately below the periodontal attachment.[2],[3]

The diagnosis of ICR can be challenging, and detection is often by an incidental radiographic finding. The radiographic appearance of ICR varies considerably depending on the size and nature of the lesion. It typically appears as an irregular, asymmetrical radiolucency through which the root canal outline is traceable.[2] Previous case reports have highlighted that cone beam computed tomography (CBCT) can provide a more accurate representation of the size, location, and nature of lesion compared to conventional radiographs.[4]

Treatment aims to inactivate the resorptive process by removing the resorptive tissue and blood supply to existing odontoclasts. Endodontic treatment followed by surgical procedures, if necessary, completely seals the resorptive defect.

Intentional replantation (IR) is defined as the purposeful extraction of a tooth to repair a defect or cause of treatment failure and thereafter the return of the tooth to its original socket.[5] It has been rarely indicated as a potential treatment option for ICR but can be considered for inaccessible lesions that require extraction.[6],[7] The present case report describes a case of ICR being managed successfully using IR.

  Case Report Top

A 27-year-old male patient, with noncontributory medical history, reported to our department with a chief complaint of a broken tooth and sensitivity in upper left front teeth region. The patient had a history of trauma 10 months back.

Clinical examination revealed complete loss of tooth #11 and Ellis Class III fracture of tooth #23 [Figure 1]a. Tooth #23 was not mobile but responded positive to percussion test and negative to thermal and electric pulp vitality tests.
Figure 1: (a) Preoperative clinical photograph (b) preoperative radiograph (c and d) cone beam computed tomography scan (e) postobturation radiograph

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Radiographic examination revealed crown fracture of #23, an isolated radiolucency approximating pulp on coronal third of distal root surface and a periapical radiolucency [Figure 1]b. CBCT findings revealed that the lesion was very closely approximating the root canal; located on distal surface of coronal third of root [Figure 1]c and [Figure 1]d.

Hence, pulpal diagnosis of necrotic pulp with periapical diagnosis of periapical abscess and Class III ICR irt #23 was made (based on Heithersay classification). The treatment plan formulated was endodontic treatment of #23 followed by IR to remove the resorptive tissue and restore the cavity with biodentine. The patient was explained about the procedure and its complications, and a written consent was obtained.

Under local anesthesia, access to the root canal #23 was established, and chemomechanical debridement was completed. Calcium hydroxide was used as intracanal medicament and after 2 weeks, the root canal was obturated using Gutta-percha cones and AH Plus (Dentsply) endodontic sealer by lateral condensation technique [Figure 1]e.

The IR was planned 2 weeks after the endodontic treatment was completed. Preliminary hematological investigations were done followed by thorough oral prophylaxis. The patient was asked to rinse with 0.2% chlorhexidine gluconate for 1 min to disinfect the surgical site.

Following local anesthesia, #23 was atraumatically extracted using dental forceps. The pressure was applied mainly above CEJ to minimize damage to the periodontal ligament (PDL) and surrounding alveolar bone [Figure 2]a and [Figure 2]b. During subsequent procedures, the tooth was constantly held with forceps above CEJ. The resorptive defect was cleaned of the granulation tissue and 90% aqueous solution of trichloroacetic acid was applied for approximately 2 min using a micro-applicator tip. The irregular borders of the defect were smoothened with a small round bur [Figure 2]c. Biodentine (Septodont) was mixed according to the manufacturer's instructions and was firmly condensed in the cavity [Figure 2]d. Until the initial set of biodentine, the tooth was covered with a wet gauze piece. Extraoral time was restricted to 12 min and the tooth was replanted back to its socket and splinted with adjacent teeth using semi-rigid composite wire splint [Figure 2]e. Correct repositioning was verified clinically and using a periapical radiograph [Figure 2]f. Postoperative instructions were given, which included rinsing with 0.2% chlorhexidine gluconate three times daily and a soft diet.
Figure 2: (a and b) Extraction of tooth (c) resorption cavity (d) resorption cavity sealed with biodentine (e) tooth replantation and splinting (f) immediate postoperative radiograph

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The patient was recalled after 7 days when the splint was removed and then after 1 and 3 months. There was no pain on percussion; and tooth mobility; periodontal probing depths and percussion sounds were all within normal limits; so a full ceramic prosthesis was fabricated [Figure 3]. The case was followed up clinically and radiographically until 18 months [Figure 4]; which showed satisfactory results with no periapical radiolucency or evidence of inflammatory or replacement resorption.
Figure 3: (a and b) 1 month follow-up (c and d) 3 months follow-up (e) 1-year follow-up

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Figure 4: 18 months' follow-up

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  Discussion Top

An ICR is an aggressive pathological lesion which can even lead to extraction of the tooth. Early diagnosis and appropriate treatment minimize the sequelae related to this problem.

The conventional intraoral radiograph does not reveal the true nature and exact location of the lesion; hence, CBCT scans are recommended for this purpose. In the case presented, differential diagnosis included subgingival caries; which was excluded by the location and hard base of the defect. CBCT examination confirmed the real extent of resorptive defect which extended till the middle third of root surface and separated from the pulp space by a very thin layer of radicular dentine; classified under the category of Heithersay Class III ICR.[3]

In the present case, IR of the tooth was planned as the resorption was on the distal aspect, well beneath the bone and reflecting a periodontal flap could not have provided adequate access to the site without healthy bone loss. But as there are many adverse outcomes of IR, such as tooth/root fracture during extraction and lower success rates, it is extremely important to understand that it should be the last choice, selected only when all the other options of treatment – nonsurgical and surgical, have been exhausted.[6],[7]

In the past, different materials have been advocated to restore the resorption cavity, i.e., Glass ionomer, light cured resin composite, and amalgam.[8] However, periodontal reattachment cannot be expected with these restorative materials. Hence, novel calcium silicate–based materials such as Mineral Trioxide Aggregate, Calcium Enriched Mixture or Biodentine can be used. Biodentine was used in the present case as it has dentine like mechanical properties and can be used as a dentine substitute on crowns and roots. Easy handling, faster setting with no discoloration of tooth is the added advantages. To inactivate the resorptive tissue before the placement of a restorative material, 90% trichloroacetic acid was used.

Common causes of failure after IR include external inflammatory resorption, replacement resorption, and tooth ankylosis.[6] An acute inflammatory reaction is expected following tooth replantation resulting in surface resorption; however, this process is self-limiting.

Surface resorption is followed by healing within 2–3 weeks. It has been reported that if <20% of the root surface is damaged, the cells of the adjacent periodontium can repopulate the area resulting healing with cementum-like tissue and reattachment of the PDL.[9] A larger area of damage has shown to cause osteoclasts to adhere to the denuded surface and result in external replacement resorption. This a continual, irreversible process and the root is gradually replaced by bone.

If the pulp of the tooth is necrotic and infected, it provides a continuous stimulus for clastic cells and can lead to extensive root surface damage in the form of external inflammatory resorption. In the case presented, #23 was endodontically treated before IR to prevent this type of resorption.

The first radiographic sign of ICR is the disappearance of the PDL space, followed by a moth-eaten appearance and replacement by bone.[2] Hence, during the IR procedure care was taken to minimize damage to the PDL cells. Only forceps were used to extract the tooth atraumatically and with minimal risk of root fracture. Furthermore, an extra-oral time of >30 min has shown to increase the possibility of replacement root resorption and ankyloses.[10] To control the extraoral time in the present case, endodontic treatment was completed before proceeding with IR procedure; which restricted the extraoral time to 12 min only.

Splinting was done to eliminate the excessive mobility of the tooth and to help the initial healing of PDL. Flexible splinting can allow physiologic mobility of the tooth and so can result in the functional arrangement of the PDL fibers. A fixation period of 1 week after replantation is generally advocated to encourage periodontal remodeling and to inhibit root resorption and ankylosis.[11] At 1-week follow-up, the patient was completely asymptomatic with regards to pain and mobility, and so the splint was removed.

The patient was called for regular follow-up after every 3 months. At an 18-month recall, the tooth was clinically sound with no radiographic evidence of inflammatory or replacement root resorption. Andreasen et al. conducted a study of 400 traumatically avulsed teeth and demonstrated that inflammatory and replacement resorption is usually detectable after 1–2 months.[10] Therefore, a 1-year observation period is likely to be sufficient to detect any pathological changes that will occur.

  Conclusion Top

  • The preservation of natural dentition is the primary goal of any conservative treatment modality
  • CBCT imaging was inevitable in the diagnosis and management of this case and should be considered for the treatment planning of ICR lesions
  • Although IR is not the primary therapy of choice, it should be considered a viable treatment option when ICR is inaccessible and not possible to restore using conventional surgical techniques.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Tronstad L. Root resorption – Etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988;4:241-52.  Back to cited text no. 1
Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:27-37.  Back to cited text no. 2
Heithersay GS. Invasive cervical resorption: An analysis of potential predisposing factors. Quintessence Int 1999;30:83-95.  Back to cited text no. 3
Patel S, Dawood A. The use of cone beam computed tomography in the management of external cervical resorption lesions. Int Endod J 2007;40:730-7.  Back to cited text no. 4
Grossman LI. Intentional replantation of teeth: A clinical evaluation. J Am Dent Assoc 1982;104:633-9.  Back to cited text no. 5
Kratchman S. Intentional replantation. Dent Clin North Am 1997;41:603-17.  Back to cited text no. 6
Dryden JA, Arens DE. Intentional replantation. A viable alternative for selected cases. Dent Clin North Am 1994;38:325-53.  Back to cited text no. 7
Frank AL, Torabinejad M. Diagnosis and treatment of extracanal invasive resorption. J Endod 1998;24:500-4.  Back to cited text no. 8
Andreasen JO, Kristerson L. The effect of extra-alveolar root filling with calcium hydroxide on periodontal healing after replantation of permanent incisors in monkeys. J Endod 1981;7:349-54.  Back to cited text no. 9
Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11:76-89.  Back to cited text no. 10
Nasjleti CE, Castelli WA, Caffesse RG. The effects of different splinting times on replantation of teeth in monkeys. Oral Surg Oral Med Oral Pathol 1982;53:557-66.  Back to cited text no. 11


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


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