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Abdelmoumen E et al
IJRD
ISSUE 1, 2015
CASE REPORT
Use of Biodentine™ in the Treatment of
Invasive Cervical Resorption: A Case Report
Ehsen Abdelmoumen*, Sonia Zouiten Skhiri**, Abdelatif Boughzela***
* DDS, Post graduate student,Department of Conservative Dentistry andEndodontics, Faculty of Dentistry of
Monastir, Tunisia. ** Professor,Department of Conservative Dentistry and Endodontics, EPS FarhatHached-Sousse,
Tunisia. *** Professor, chief department of dental medicine, EPS FarhatHached-Sousse, Tunisia.
Address for correspondence: EhsenAbdelmoumen, Faculty of dentistry of Monastir, Department of Conservative Dentistry and
Endodontics, Street Avicenne 5000 Monastir.
Mob: +21698383315
Email: dr.ehsen@hotmail.fr
Abstract : This paper report a case describing the diagnosis and treatment of an external root resorption in the upper right central
incisor with surgical approach following endodontic treatment using the new dental cement Biodentine™ in an attempt to repair the
defect. Early diagnosis and appropriate treatment are the keys to a successful outcome. This case report presents a favorable clinical
outcome when Biodentine was used for treating external cervical resorption.
Keywords: biodentine; dental trauma; external cervical resorption; surgical management.
surgery, periodontal treatment and a wide variety of
traumatic conditions (2,3)
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Frequently, cervical resorption are confused and
misdiagnosed as caries and internal resorption,
INTRODUCTION
External root resorption is a progressive and
destructive loss of tooth structure, initiated by a
mineralized or denuded area of the root surface.
Invasive cervical resorption is a clinical term used to
describe a relatively uncommon, insidious, and often
aggressive form of external root resorption.(1) It is
seen in most cases as a late complication of
traumatic injuries of the teeth, but it may also occur
after
internal
bleaching,
orthodontic
tooth
movement, orthognathic and other dento-alveolar
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leading to improper treatment or unnecessary loss of
the tooth (4) Materials such as amalgam, composite
resin, glass ionomer, and mineral trioxide aggregate
(MTA) have been used in past for restoring the
resorptive defect (Isidoret al., 2006). The present
case involved the use of new calcium silicate-based
cement called Biodentine (Septodont, Saint-Maurdes-Fosses, France) for the treatment of an invasive
cervical resorption in the maxillary right central
incisor.
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Abdelmoumen E et al
CASE REPORT
IJRD
ISSUE 1, 2015
The tooth was isolated with
wi a rubber dam after the
A 35 year-old healthy male patientt ppresented to the
Department
Dentistry
of
and
Department
Endodontic
off
Conservative
EPS
S
FarhatHached
(Sousse -Tunisia) with no symptomss but with labial
gingival inflammation in the maxilla
llary right incisor
region.The
patient
reported
a
history
of
trauma.Endodontic testing found that
hat the tooth was
non tender to pressure and percussion
on and responded
negatively to cold compared with the
he adjacent teeth.
The labial gingival tissue was infl
nflammatory and
slightly tender to palpation with the
th presence of
periodontal pocket (Figure 1).Periapi
pical radiographs
showed an apparent radiolucency iin the cervical
third of the root canal, involv
lving the root
canalassociated to a peri-apical radiol
iolucency (Figure
2).On the basis of history, clinicall examinationand
e
radiographic findings a diagnosis of
o chronic periapical periodontitisand external cerv
rvical resorption
(class 3 invasive cervical resorption
ion as described
byHeithersay). The patient was given
giv
a detailed
explanation concerning the plan
anned treatment
application of local ane
nesthesia. A conventional
access cavity was prepa
pared.The root canal was
cleaned and shaped usin
sing rotary nickel-titanium
Revo-S
®
instruments
ts
(Micro-Mega,Besançon,
France) in a crown down
wn approach. The working
lengths were determined
ed using electronic apex
locator (Rootor, META
A BIOMED, Korea) and
established
working
lengths
le
were
controlled
radiographically (Figure 3).During
3
preparation, the
canals were copiously irrigated
irr
with 2.5% sodium
hypochlorite and 17% EDTA.
ED
Calcium hydroxide
paste
(MM-Paste™,
Micro-Mega,
M
Besançon,
France) was placed as ann intracanal medication and
the access cavity was sealed
s
with a temporary
filling(MD-Temp™ ,MET
TA Biomed co, Korea) .On
the subsequent visit (2 weeks
w
later), as the patient
was completely asymptom
tomatic, the root canal was
rinsedthoroughly, dried with
wi the help of paper points
and obturated using la
lateral cold condensation
technique.
2
3
procedure and prognosis. This inc
ncluded surgical
exposure, debridement, and restoratio
tion proceeded by
endodontic treatment.Consent was rec
received from the
patient.
Fig.2: Periapical radiograph of tooth 11 showing a radiolucent
area at the distal aspect of the tooth and periradicular
radiolucency. Fig.3: Work
orking length determination.
An
immediate
post-ope
operative
radiograph
was
performed to control thee quality of thre root canal
obturation. An excess of gutta-percha observed in
Fig 1: Pre-operative extraoral view: gingiv
ival inflammation.
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the resorptive cavity will
ill be removed later (Figure
4).As the lesion was clinically
cli
not accessible, a
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Abdelmoumen E et al
IJRD
ISSUE 1, 2015
surgical approach opted to repair the resorptive postoperative complaints were noted and the patient
defect; after administering anesthesia (Figure 5a),
intrasulcularincisions were made on the labial aspect
wascompletely free of pain.
7(a)
7(b)
of maxillary right central incisor (Figure 5b)and 2
vertical incisions to complete the full-thickness flap
(Figure 5c). The resorption cavity was curetted
toremove the devitalized tissue and the excess of
gutta-percha (Figure 6a). The irregular borders of
Fig.7: a: Biodentine™ mixed according to the manufacturer’s
instructions, b: consistence of the Biodentine™.
the defect were smoothed with a bur and the cavity
wasthoroughly
irrigated
with
sterile
saline
solution(Figure 6b).
4
5(a)
5(b)
Fig.8: Placement of the Biodentine™
Clinical and radiographic follow up for 12 months
showed satisfactory results witharrest of root
5(c)
resorption and progressive healing of the defectand
the periapical lesion (Figure 10).Subsequent recalls
Fig.4: Root canal filling, excess of gutta-percha in the
resorptive cavity. Fig.5: a: anesthesia administration, b:
intrasulcular incision, c: vertical incisions.
were planned at 6-month intervals. However, the
patient moved to another city and could not be
6(b)
6(a)
controlled for further recall visits because of this
relocation.
9(a)
9(b)
Fig.6: a: Removal of gutta-percha excess and resorptive tissue,
b: Clinical view of the debrided resorptive lesion (before
placement of the restoration).
Biodentine™
was
mixed
according
to
the
manufacturer’s instructions(Figure 7a-b) and was
firmly condensed in the cavity (Figure 8). The flap
Fig.9: a: Flap repositioned &sutured, b:Immediate radiograph
after surgical repair of the lesion.
wassutured in place and postsurgical instructions
were given to the patient (Figure 9 a). An immediate
Fig.10: 12months follow-up
post-operative radiograph was performed to control
the sealing of the resorptive cavity (Figure 9b). A
week
later,the
sutures
were
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removed.
No
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Abdelmoumen E et al
DISCUSSION
IJRD
ISSUE 1, 2015
sometimes resemble caries. ECR can be found in
External cervical resorption(ECR) is the loss of
dental hard tissue as a result of odontoclastic action.
This inflammatory tissue loss occurs immediately
below the epithelial attachment of the tooth(5).The
exact cause of External cervical resorption is poorly
understood, several etiologic factors have been
suggested that might damage the cervical region of
the root surface and therefore initiate external
cervical
resorption:
these
trauma,orthodontic
bleaching,
include
treatment,
periodontal
dental
intracoronal
therapy,and
idiopathic
etiology (6, 7).Heithersay (1999) classified ECR
according to the extent of the lesion within the tooth:
class 1; a small invasive resorptive lesion near the
cervical area with shallow penetration into dentin;
class 2; a well-defined invasive resorptive lesion that
has penetrated close to the coronal pulp chamber but
shows little or no extension into radicular dentin,
class 3; a deeper invasion of dentin by resorbing
tissue, not only involving the coronal dentin but also
extending at least to the coronal third of the root and
class 4; a large invasive resorptive process that has
extended beyond the coronal third of the root canal
(8) . A pink spot in the cervical region of the tooth is
usually the clinical sign noticed by the patient and/or
dentist that brings the problem to light. If there is no
pink spot indicating ECR, then the condition might
go unnoticed until there is pulpal and/or periodontal
involvement, because these lesions are usually
painless.External cervical resorption defects are
commonly
detected
as
chance
findings
on
radiographs. The lesions vary from well-delineated
radiolucencies that are quite obvious to poorly
defined
lesions
with
irregular
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borders
and
one or multiple teeth. When it is diagnosed in one
tooth, it is important to carefully examine the rest of
the
teeth
clinically
and
radiographically
for
additional occurrences of ECR.Thelarger lesions can
also
be
misdiagnosed
as
cariesor
internal
resorption.(9) The usual indication that thelesion is
not
carious
is
the
irregularity
of
the
radiolucencyand/or the radiopaque outline of the
protectivepredentine layer of the pulp .Byutilising
varying angulation of the radiographs,internal
resorption can be ruled out. If the lesion isdue to
internal resorption, it will remain centeredwhat the
direction, or “off-angle” the radiograph is taken.
However, if the lesion is one of ICR, Clark’sRule, or
SLOB Rule, can be used to determine thelocation of
the lesion (the most lingual object moveswith the
direction of the X-ray head) (9).With the advent of
CBCT, the clinician is given the opportunityto view
teeth
and
anatomical
entities
in
three
dimensions.(10) Itallow the clinician to makea more
definitive diagnosis and establish a confidentand
realistic
plan
for
treatment,
with
a
higherpredictability of success(11, 12).Treatment
options were discussed with the patient. It depends
on the severity, location, whether the defect has
perforated
the
root
canal
system,
and
the
restorability of the tooth. Generally, there are three
choices for treatment: [1] no treatment with eventual
extraction when the tooth becomes symptomatic; [2]
immediate
extraction;
or
[3]surgical
access,
debridement, and restoration of the resorptive lesion
(without/with
endodontic
treatment)
(10).Appropriate treatment should aim at the
inactivation of all resorbing tissue and
the
reconstitution of the resorptive defect by the
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Abdelmoumen E et al
IJRD
ISSUE 1, 2015
placement of a suitable filling material.Treating filling material in endodontic surgery) and pulp
invasive cervicalresorption lesions with a chemical
capping and can be used as a dentine replacement
agent,
(TCA)
material in restorative dentistry.It has been proposed
afterprotective application of glycerol to adjacent
as a favorable repair material as it can be placed in
soft tissues, before the curettage ofthe lesion is
permanent and close contact with periodontal tissue
advocated by Heithersay (7).The TCA was not used
due
in this case, because theisolation of the surrounding
(15).Compared to MTA, Biodentin hasa better
tissues in the surgical area could not bemaintained as
consistency after mixing which allows easeof
a result of the localization of the defect.After
placement in areas of resorptive defect and
chemomechanical debridementof the defect, many
needsmuch less time for setting (6).Although case
materials have been used to seal the resorptive
reports are definitely important resources of
cavity such as amalgam, composites and glass
confirming a material's suitability for clinical usage,
ionomer and Mineral trioxide aggregate(MTA)(13).
it is undeniable that more reliable results can be
Surgical treatment of varying degrees ofinvasive
achieved through randomized long-term clinical
cervical
involved
trials. Accumulation of data of long-term clinical
periodontal flapreflection, curettage, restoration of
trials after a prolonged period might lead to
the defect with amalgam,composite resin, or glass
gathering of evidence based data; such has been for
ionomer cement, and repositioning theflap to its
mineral trioxide aggregate. Though the chemical
original position. Periodontal reattachment cannot be
characteristics and general features of Biodentine are
expectedwith amalgam or composite resin and is
similar, it is clear that a specific number of clinical
unlikely with glassionomer cementbut there is
trials
experimental evidence to suggest thatthis might be
conclusions can be drawn (15).
90%
trichloroacetic
resorption
has
acid
generally
possible if MTA is used in this situation (14).
Therefore, MTA® was extensively used and
to
itsbioactivity
should
be
and
conducted
biocompatibility
before
definite
CONCLUSION
considered for many practitioners the material of
It is important for endodontist to understand the
choice to seal the resorption (3). Biodentine™is a
periodontal and restorative aspects of treating ECR.
new calcium silicate–based materialwhich became
Teeth with ECR are often structurally compromised
commercially available in 2009 and that was
and may eventually fail even though the endodontic
specifically designed as a “dentine replacement”
treatment is successful. The endodontic treatment is
material. The material is actually formulated using
irrelevant if the resorption is not eliminated, and the
the
the
restorative aspects are not managed properly. Proper
improvement of some properties of these types of
management requires knowledge and skills in
cements, such as physical qualities and handling
endodontics, surgery, and restorative dentistry, and
(15)Biodentine™ has a wide range of applications
elimination of the resorption is performed most
including endodontic repair (root perforations,
effectively under a microscope.Invasive cervical
apexification, resorptive lesions, and retrograde
resorptionin advanced stages may present great
MTA-based
cement
technology
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and
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Abdelmoumen E et al
IJRD
ISSUE 1, 2015
challenges for clinicians. Therefore, preventionand 5.Patel S, Kanagasingam S, Ford TP (2009) External
early detection must be stressed when dealing with
Cervical Resorption: A Review.J Endod 35(5), 616-
patients presenting history ofpotential predisposing
25.
factors.
6.Nikhil V, Arora V, Jha P, Verma M(2012) Non
Biodentine, a popular and contemporary tricalcium
surgical management of trauma induced external
silicate based dentine replacement and repair
root resorption at two different sites in a single tooth
material, has been evaluated in quite a number of
with Biodentine : A case report. Endodontology
aspects ever since its launching in 2009 . The studies
24(4), 150-5.
are generally in favor of this product in terms of
physical and clinical aspects despite a few
contradictory reports. However, further studies are
necessary to provide more information about the use
of Biodentine for the treatment of resorptive defects
and obturation of pulp space.
7. Heithersay
GS( 2004) Invasive cervical
resorption. Endod Topics 7, 73-92.
8.HeithersayGS(1999)
Treatment
of
Invasive
Cervical Resorption: An Analysis of Results Using
Topical
Application
of
Trichloracetic
Acid,
Curettage, and Restoration. Quintessence Int 30, 96-
CONFLICT OF INTEREST:
110
There is no conflict of interests to declare.
9.Stropko JJ(2012) Invasive cervical resorption
REFERENCES:
(ICR): A description, diagnosis and discussion of
1.Park JB, Lee JH (2008) Use of mineral trioxide
aggregrate in the non-surgical repair of perforating
optional management-A review of four long-term
cases. Roots 4, 6-20
invasive cervical resorption. Med Oral Patol Oral
10.Schwartz RS, Robbins JW, Rindler E (2010)
Cir Bucal13(10), E678-80.
Management of Invasive Cervical Resorption:
2.Salgar AR, Chandak MG, Manwar NU (2011)
Surgical endodontic management of external root
3.Yilmaz HG, Kalender A, Cengiz E(2010) Use of
Mineral Trioxide Aggregate in the Treatment of
Invasive Cervical Resorption: A Case Report.J
Endod36(1), 160-3.
SK
Subramanyappa,
Management of A Class III Invasive Cervical
Resorption Using A New Biomaterial.Inter J Res
Dent 4 (3), 174-81.
12. Baad I, Agrawal S(2012) Diagnostic Role Of
Parthasarathy
B,
Manjegowda PG, Rajeev S (2012) Management of
Perforating
Report of Three Cases.J Endod 36 (10), 1721-30.
11. Pruthi PJ, Yadav P, Kaur H,Talwar S (2014)
resorption.Inter J Dent Clin 3(2) ,93-94.
4.
Observations from Three Private Practices and a
Invasive Cervical Resorption: Two
Case Reports.JIndAcad Oral Med Rad 24(4), 346-9.
Cone Beam CT In The Management Of Resorption
In Maxillary Anterior Teeth.Int J Dent Pract Med
Sci1(1), 1-4.
13. Hommez GMG, Browaeys HAA, De Moor
RJG(2006) Surgical Root Restoration After External
Downloaded from www.jrdindia.org
- 15 -
Abdelmoumen E et al
IJRD
Inflammatory Root Resorption: A Case Report.JOE
ISSUE 1, 2015
32(8) ,798-801.
14.Kim Y, Lee CY, Kim E, Roh BD (2012) Invasive
cervical resorption: treatment challenges.Rest Dent
Endod 37, 228-31.
15. MalkonduÖ, KazandağMK, KazazoğluE (2014)
A Review on Biodentine, a Contemporary Dentine
Replacement and Repair Material.Biomed Res
Int2014:160951.
How to cite this article:
Abdelmoumen E, Skhiri SZ, Boughzela A. Use of Biodentine™ in the Treatment of
Invasive Cervical Resorption: A Case Report. IJRD 2015;4(1):10-16.
Downloaded from www.jrdindia.org
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