Root Resorption BDS 11139 Lecture Notes PDF

Root Resorption BDS 11139 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To explain types of root resorption 2. To explain the causes of root resorption 3. To detail how to diagnose and manage root resorption injuries Objectives: On completion of this lecture, the student s...

Root Resorption BDS 11139 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To explain types of root resorption 2. To explain the causes of root resorption 3. To detail how to diagnose and manage root resorption injuries Objectives: On completion of this lecture, the student should have: 1. An understanding of how to diagnose root resorption clinically and radiographically 2. An understanding of how to manage different types of root resorption It is a Physiologic or Pathologic process which results in the loss of Dentin, Cementum of the root of the tooth. 3 Resorption Physiological It occurs in primary dentition. It is normal root resorption for shedding Pathological Pathogenesis: No resorption occurs in permanent teeth , unless a pathological condition occurs. The root surface of permanent teeth is protected by their nonmineralized structural components :  From inside the canal by pre-dentine and odontoblasts in the root canal.  From outside the canal by Pre-cementum & Cemento-blasts. The cells responsible for resorption of dental hard tissues are multinucleated giant cells classified as clasts. The mechanism is the same in bone and root. The resorptive cells (osteoclasts in bone or dentinoclasts in the root) remove organic material so the inorganic salts loose their framework to be carried away by macrophages & tissue fluids. Organic material breakdown Inorganic framework dissolution Requirements for Root Resorption Occurrence INJURY of (nonmineralized) Pre D – Pre C by chemical or physical factors + further stimulation of the resorptive cells by pressure or infection result in continuation of the resorption 1/24/2023 Without further stimulation of the resorptive cells the process will stop and Free template from www.brainybetty.com repair occur Internal Root Resorption External Internal root resorption 1- Etiology 2-Types 3- Diagnosis 4- Treatment 1-Etiology of Internal Root Resorption: - The exact etiology is still unknown. - Damage of protective odontoblast/predentin layer--exposing the underlying minerlaized dentin to odontoclasts. - Factors of resorption: A)Insult. B) Dentinoclast cells from U.M.C C) Sufficient vascular element. It is initiated by damage to or loss of the predentine and odontoblast layer and sustained by pulpal inflammation Factors that may injur the protective predentine and odontoblast cells. 1- Dental trauma. 2-Overheating and dehydration during restorative procedures, 3-Use of cytotoxic restorative materials or dressing materials in pulpotomies. 4- Caries , periodontal infections 5-Orthodontic tooth movement. 6)Herpes zoster: varicella zoster virus remains dormant in nerve ganglion from an earlier chickenpox attack and can be become reactive and infect pulp 7) Idiopathic 2-Types Of Internal Root Resorption: Internal resorption Transient Progressive Replacement  1-Transient : Occur in: A recent traumatized teeth. Teeth that have undergone periodontal treatment or orthodontics. Self limiting & repaired by itself. Repair with the formation of a cementum-like tissue( unless there is a continuous stimulation). It has no clinical consequence.  2-Progressive : – Requires continuous stimulation by infection. – occur in the presence of: infection. certain systemic diseases. increased pressure in tissue. – Progress from inside to outside till perforation occur. (a) The pathogenesis of internal inflammatory root resorption. The canal coronal to the resorption is necrotic and invaded by microbes. The resorption cavity contains highly vascularized resorption tissue with multinuclear odontoclast cells (b) A close-up image of the resorption. 3-Replacment: The resorbed dentine is replaced by calcified substance (osteodentne) similar to bone. Radiographically ,the defect has a somewhat mottled or clouded appearance as a result of the radiopaque nature of the calcified material occupying the lesion 3-Diagnosis Of Internal Resorption: A-Clinical : Clinically, the early stages of internal resorption are usually asymptomatic. A pink spot may be present on the crown if resorption takes place in the pulp chamber. A-Clinical : Sensitivity tests: Internal resorption is usually associated with vital pulp in the early stages which then later become necrotic after perforation occurs. B-Radiographically: Mistaken with caries but caries is seen clinically. Smooth sharply defined margins, that can be clearly defined. Pulp shadow disappears into the lesion, where the pulp runs in a continuous sharp line & suddenly disappears in the area of the lesion. On applying tube shift the lesion within the confinement of the root. Its position will not change Radiographically: Internal resorption affecting the maxillary lateral incisor, the pulp became infected and apical periodontitis developed A periradicular radiolucency may be associated with perforation of the root or total necrosis of the pulp Internal resorptive lesions remain undetected and may only appear incidentally on a postobturation radiograph 4-Treatment options of internal root resorption: Root-canal treatment should be carried out immediately after detection in order to prevent further disease progression leading to root perforation. Treatment Non surgical RCT Recalcification with ca(OH)2 MTA Surgical 1) Non Surgical Treatment: It is the treatment of choice when resorptive defect does not perforate the root canal. Problems: Hemorrhage Inaccessible recesses Obturation phase Hemorraghe Inaccessible recess Obturation phase The pulp is vital, so Standardized root canal Using lateral presence of a huge instruments can not reach condensation technique defect in the tooth through an area of defect. so will result in inadequate containing vital pulp we can not make a proper filling of the resorptive tissue will cause cleaning & shaping. defect, haemorrhage during root canal treatment. Solution: We can use endodontic Use thermo-plasticized Using ultrasonic file to clean the injection technique to vasoconstrictor. pulp remnants in the fill the defect: Irrigation with inaccessible areas Fill the apical one third sodium (Acoustic Streaming ). with lateral hypochlorite Calcium hydroxide as an condensation (NaOCl), it will intracanal, antibacterial &complete with assist in controlling medicament to thermo-plasticized haemorrhage & supplement the technique. dissolving the pulp conventional chemotissue in the mechanical debridement inaccessible of the root canal system recesses 2) Re-calcification by calcium hydroxide. Indication: Teeth with small perforated defect i.e. (internal resorption) that not communicate with the gingival sulcus. Contraindication: If there is a communication with gingival sulcus, in which Ca(OH)2 will be dissoluted by the action of saliva &its function is impaired. Technique: – Ca (OH)2 powder is mixed with either: Anesthesia or Saline to form a thick paste. – Introduced into the canal with endodontic plugger. – Controlled pressure is needed to fill the canal completely with Ca (OH)2 & fill the perforation as well &get in contact with the periodontal ligament. – Recall the patient after 6 weeks to change the dressing & make a radiograph. – Follow up after 6-12months to make sure that new hard tissue was deposited. this is done by x ray, then carry out normal root canal treatment 3) Mineral Trioxide Aggregate: Teeth with small perforated defect i.e. (internal resorption) that not communicate with the gingival sulcus. Preferred material to seal the defect due to its setting in moisture or blood, biocompatibility &high alkalinity allowing hard tissue repair Filling the canal totally with MTA along with perforative resorptive defect OR The apical portion is filled with gutta-percha till the defect, and the resorption defect and associated perforation are sealed with MTA 4) Surgical treatment: When non surgical & re-calcification can not be met or have been unsuccessful, surgical approach is done by exposing and sealing the resorptive defect surgically. Indications:  Uncontrolled bleeding from the perforation defect.  Perforation communicating with gingival sulcus.  Unsuccessful recalcification. When internal resorption has rendered the tooth untreatable or un-restorable, extraction is the only treatment option External root resorption 1- Etiology 2-Types 3- Diagnosis 4- Treatment 1-Etiology of External Resorption: 1- Inflammation and infection: - Pulp - Periodontal 2- Orthodontic treatment 3-Traumatic injuries ( intrusion, luxation injuries, avulsion) 4- Replantation of teeth - Surface - Inflammatory - Replacement 5- Impaction 6- Tumors and cysts 7- Chemical trauma 8- Systemic condition 9- Idiopathic. 1-Inflammation and infection: Pulpal: Root-canal infection causing inflammation in the periodontal ligament adjacent to the denuded area of root surface. Periodontal (cervical) Presence of microbes due to: Periodontal pocket or any infection in the periodontal ligament leads to reduction in periodontal pH leading to decalcification of bone & tooth structure 2-Orthodontic treatment: Continuous pressure, which exceeds the level of peridontal membrane resistance so: The tissue can not tolerate. No time for repair. leading to necrosis of peridontium. Macrophage while trying to remove necrotic tissue will release prostaglandin which activates osteoclastic activity and lead to root resorption. The treatment of this condition is removal of pressure source, then root canal treatment can be done. 3-Traumatic injuries ( intrusion, luxation injuries, avulsion) 4-Re plantation of teeth:  Root resorption ranges between 8095%.  3 types of root resorption occur after replantation:  Surface.  Inflammatory.  Replacement.  More than one type can be seen radio-graphically in some teeth. 5-Impaction: Impacted teeth in place will compress the surrounding structures & disturb the blood supply and act as mechanical stimuli for external root resorption of adjacent teeth 6) Tumors and cysts: Causes of resorption: a. Mechanical: through pressure. b. Secretion of local factors to expand the lesion, which causes resorption of the adjacent structure either dental or bone structure. 7) Chemical trauma: Bleaching agent contains O2 which is caustic leak via dentinal tubules to periodontal membrane space leading to inflammatory resorption (Cervical resorption is a post bleaching resorption). 8) Systemic condition: Some systemic conditions may cause disturbance in endocrine system and normal calcium metabolism, e.g.: – Hypo-parathyroidism. 1/24/2023 Free template from www.brainybetty.com 37 2-Classification of External Resorption: External Resorption Surface Inflammatory Replacement A. Surface Resorption ( transient external resorption): It is the simplest type. Small superficial cavities affecting: Cementum. Or Outer most layer of dentin. It is self-limiting and undergoes spontaneous repair with new cementum. Surface resorption is rarely evident on the radiograph. B-Inflammatory Resorption: Pulpal or periodontal inflammation or infection Management : 1-Thorough chemomechanical debridement of the root canal using sodium hypochlorite for irrigation 2-Calcium hydroxide for interappointment dressing. Pressure resorption: Orthodontic treatment. Tumours and cysts Impaction Occlusal trauma Management: Removal of the cause which arrests the resorption. Follow-up and Prognosis of External Inflammatory Resorption: Healing of EIR is characterized radiographically: 1-Cessationof the resorption process, 2-Resolution of the radiolucency in the adjacent bone, and 3-Reestablishment of the PDL space. C- Replacement Resorption: Severe trauma leading to ankylosis disrupted periodontal ligament surface resorption of cementum and dentin which is replaced by bone It is usually a consequence of: Luxation injuries Replantation of avulsed teeth when extensive loss of viability of periodontal ligament and damage of cementum Diagnosis: Clinically: The involved tooth is asymptomatic. High-pitched metallic sound on percussion. Absence of physiological tooth movement The tooth may be in infra-occlusion in a growing child. Radiographically: The root appears to be gradually replaced by bone. The periodontal ligament space is not evident. External resorption can be classified according to site into: Apical: P.A.inflammation or over instrumentation 1-Conventional method: Tailor made Inverted cone MTA plug ( apical closure techniques) 2-Surgical method: Continuous apical resorption. Persistence peri-apical pathosis. Cervical: Inflammation. Trauma. Chemicals. Lateral: luxation injuries (where the tooth has been displaced). Non surgical endodontic treatment with Ca(OH)2 dressing is needed and follow up. Cervical Root Resorption: It is initiated by damage to the cervical attachment apparatus (cementum or periodontal ligament) below the epithelial attachment. Causes:  Orthodontic tooth movement,  Subgingival scaling and root planning,  orthognathic and dentoalveolar surgery  Internal bleaching agents 1/24/2023 Free template from www.brainybetty.com45 Heithersay classification of invasive cervical resorption. Class 1 denotes a small invasive resorptive lesion near the cervical area with shallow penetration into dentin; Class 2 denotes a well-defined invasive resorptive lesion that has penetrated close to the coronal pulp chamber but shows little or no extension into the radicular dentin; Class 3 denotes a deeper invasion of dentine by resorbing tissue, not only involving the coronal dentin but also extending into the coronal third of the root; Class 4 denotes a large invasive resorptive process that has extended beyond the coronal third of the root Clinically The tooth is asymptomatic in early stages on but will develop symptoms of pulpitis in the advanced stages ( when perforation occurs. On exploration with a probe, a subgingival, supracrestal noncarious cavity may be detected. A pink spot will be present when the inflammatory tissue undermines the enamel of the crown. The pulp remains vital in most cases. Radiographically: The resorptive lesion may present as a an irregular radiolucency involving the buccal, lingual or proximal surface of the tooth. Nevertheless, the outline of the pulp and root canal can be distinguished through the resorptive lesion. Adjacent angular alveolar bone loss may be noticed when the lesion involves proximal surfaces. Treatment of External Cervical root Resorption Depends on : Position of the defect in relation to epithelial attachment 1-Accessible defect (above or at the epithelial attachment) Perforating Not perforating 2-Inaccessible resorptive defect (below epithelial attachment), Perforating Not perforating 1-Accessible defect (above or at the epithelial attachment) Not perforating 1- Excavate the resorptive defect. 2- The cavity is treated with a 90% aqueous solution of trichloracetic acid; (causes coagulation necrosis of the resorptive tissue without damaging the periodontal tissue) 3- Restore the hard tissue defect with an aesthetic filling material (composite resin , glass ionomer, biodentine as it supports PDL attachment) Perforating Endodontic treatment+ restoration of the defect 2- Inaccessible resorptive defect (below epithelial attachment) Not perforating Surgical access to the site of resorption is gained by raising a mucoperiosteal flap,. The resorptive cavity is excavated Glass ionomer cement should be used to restore the defect. Perforating Re-calcification with hydroxide. Endodontic treatment. calcium If failure of recalcification, surgical treatment is indicated to expose the resorptive defect ,Glass ionomer cement should be used to restore the defect & RCT is performed. Differential diagnosis between internal and external resorption Pink spot Internal resortion External cervical resorption Cervical resorption may be confused with internal resorption because of: It may undermine the enamel leading to appearance of the classical pink spots of the internal resorption. To diffreniate on Probing: Red inflamed gingiva bleeding due to granulation tissues in case of cervical resorption Radiographic examination with different shifts will be helpful in differential diagnosis. Differential diagnosis of internal & external resorption by x ray Internal External Smooth sharply defined margin, that can be clearly defined. Ragged margins Pulp shadow disappears Shadow of the pulp into the lesion, where the passes through the pulp runs in a continuous lesion un changed. sharp line &suddenly disappears in the area of the lesion. Internal External Using shift technique (buccal object rule) (Changing the horizontal angulation) the lesion within the the lesion is confinement of the superimposed on the root. pulp. Its position will not Its position will change change Recently CBCT is used to:  Differentiate between internal and external resorption  Determine the lesion size  Whether it is perforating or not 57 Sensitivity tests: Internal resorption: usually associated with vital pulp in the early stages which then later become necrotic after perforation occurs. External resorption: -( External inflammatory)Apical & lateral aspects: negative response -Cervical: Mostly positive response unless there is pulpal involvement. 1/24/2023 Free template from www.brainybetty.com 58 Aims: The educational aims of this lecture are: 1. To explain types of root resorption 2. To explain the causes of root resorption 3. To detail how to diagnose and manage root resorption injuries Objectives: On completion of this lecture, the student should have: 1. An understanding of how to diagnose root resorption clinically and radiographically 2. An understanding of how to manage different types of root resorption Reading material: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapter 25) 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. (chapter 16) 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. (chapter 10) 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. (chapter 6) Thank You