Article published online: 2021-11-01

Case Report

Diagnosis and Management of Root Resorption in Traumatized

Teeth: Report of Two Cases
Thiago Farias Rocha Lima, Julio Vargas Neto1, Adriana de Jesus Soares1
Department of Restorative Dentistry, Federal University of Paraíba, João Pessoa, PB, 1Department of Restorative Dentistry, State University of Campinas,
Piracicaba, SP, Brazil

Abstract
Internal resorption (IR) is a progressive process initiated within the pulp space with the loss of dentin. Although trauma and pulp
inflammation/infection are the major contributory factors in the initiation of IR, all the etiologic factors and the pathogenesis have not yet
been completely elucidated. Cervical external resorption is defined as a localized resorptive process that commences on the surface of the root
below the epithelial attachment and the coronal aspect of the supporting alveolar process, namely, the zone of the connective tissue attachment.
This report is presented two cases of root resorption (external cervical resorption and inflammatory IR) in traumatized teeth where cone beam
computed tomography has been used as an important diagnostic tool. Treatment of external cervical resorption involved endodontics and
periodontics. In case with inflammatory IR, only endodontic treatment was necessary. The postoperative course was uneventful and a stable
clinical outcome was obtained.

Keywords: Cone beam computed tomography, dental trauma, root resorption

Introduction surgical intervention to treat progressive external root

resorption is necessary, glass‑ionomer, resin composite,
Internal resorption (IR) is a progressive process initiated within
mineral trioxide aggregate (MTA), and biodentine can be
the pulp space with the loss of dentin. Although trauma and pulp
uses for to repair the destroyed area.[3,7,8] In IR, when not
inflammation/infection are the major contributory factors in the
communicating with the periodontium, only endodontic
initiation of IR, all the etiologic factors and the pathogenesis
treatment is recommended.[3]
have not yet been completely elucidated.[1,2] Cervical external
resorption is defined as a localized resorptive process that This article presents two cases reports of root resorption where
commences on the surface of the root below the epithelial CBCT has been used as an important diagnostic tool and has
attachment and the coronal aspect of the supporting alveolar aided in deciding the appropriate treatment plan.
process, namely the zone of the connective tissue attachment.[3,4]
Diagnosis of root resorption is possible after a complete Case Reports
clinical and radiographic examination. Currently, cone beam Case report 1
computed tomography (CBCT) has proven to be an important A 30‑year‑old woman visited the Dental Trauma Service at
diagnostic tool in endodontics.[5,6] CBCT scans allow images the Piracicaba Dental School (University of Campinas) for
to be viewed in the axial, coronal, and sagittal slices and are
important for the diagnosis of root resorption. In addition,
Address for correspondence: Prof. Thiago Farias Rocha Lima,
CBCT allows a detailed assessment of the resorbed area so that Department of Restorative Dentistry, Federal University of Paraíba,
the exact location and extent can be determined, ensuring the Endodontics Area, University City, SN,
establishment of a more effective treatment plan.[3] João Pessoa, PB 58051‑900, Brazil.
E‑mail: [email protected]
In many clinical cases, the treatment of cervical external
resorption involves endodontics and periodontics.[3,4] When
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DOI: How to cite this article: Lima TF, Neto JV, de Jesus Soares A. Diagnosis
10.4103/ejgd.ejgd_138_16 and management of root resorption in traumatized teeth: Report of two
cases. Eur J Gen Dent 2017;6:127-30.

© 2017 European Journal of General Dentistry | Published by Wolters Kluwer ‑ Medknow 127
 Lima, et al.: Management of root resorption in traumatized teeth

the evaluation of tooth 21. During the anamnesis, the patient the canal with paper points, the root canal was filled with
reported a bicycle accident at 8 years of age old that caused an gutta‑percha plasticized cones and AH Plus sealer (Dentsply
enamel and dentin fracture in teeth 11, 12, and 21. Clinically, Maillefer, Petrópolis, Brazil). The tooth was then sealed
tooth 21 did not respond to pulp sensitivity testing (Endo–Frost, with coltosol (Coltene Whaledent, NJ, USA) and composite
Roeko, Langenau, Germany), and the patient reported no resin (Filtek; 3M Espe, Sumaré, Brazil) [Figure 1c].
pain on percussion and palpation. Radiographic examination
After 3 days, the patient reported no symptoms when she
showed a radiolucent area in the cervical region of tooth 21,
returned for surgical repair of cervical external resorption.
thereby suggesting external cervical resorption. No periapical
The patient was anesthetized, and an intrasulcular incision
lesion was observed [Figure 1a].
was made with a detachment of the mucoperiosteal flap. The
CBCT was performed (Galileos; Sirona Dental, Bensheim, resorption area was exposed, and curettage of the granulation
Hessen, Germany) to determine the extent and depth of the tissue was maintained. Subsequently, the area was irrigated
lesion in the three spatial levels. Based on the CBCT images copiously with saline solution, the bleeding was controlled,
and three‑dimensional (3D) reconstructions [Figure 1b], a and the cavity was restored with resin‑modified glass ionomer
diagnosis of cervical external resorption of Heithersay’s[9] cement (Vitremer; 3M, St. Paul, MN, USA). The area
class II was determined. The treatment plan included was then closed with sutures, which were removed 7 days
endodontic treatment and surgical intervention for removal of later [Figure 2]. After a follow‑up of 18 months, the patient
the inflamed granulation tissue that occupied the lesion cavity reported no symptoms and examination revealed a lack of
and repair of the resorption defect with resin‑modified glass periapical changes [Figure 1d].
ionomer cement.
Case 2
After the patient was anesthetized, the crown was accessed A 25‑year‑old male was referred to the Dental Trauma Service
followed by absolute isolation. Root canal was cleaned and at the Piracicaba Dental School (University of Campinas) for
shaped up to the size of the R40 (40.06) instrument of the the evaluation of tooth 21. During the anamnesis, the patient
RECIPROC system (VDW, Munich, Germany). Odontometry reported experiencing dental trauma at 7‑year‑old, but he did
was performed using an electronic apex locator (Novapex; not remember the details of the accident. Clinically, the dental
Forum Technologies, Richion, Le‑Zion, Israel). Root canal crown was not darkened, and all anterior teeth responded to the
was irrigated with 2.5% NOCl. All procedures were performed sensitivity test (Endo‑Frost). The patient reported no pain upon
under the magnification of a surgical microscope. Before root percussion or palpation. Radiographic examination revealed
canal filling, An Irrisonic E1 (20/.01) tip (Helse Industria e that the absence of periapical lesions, but inflammatory IR
Comercio, Santa Rosa de Viterbo, Brazil) fitted to an ENAC in tooth 21 [Figure 3a]. Given these clinical observations,
ultrasonic handpiece (Osada Electric Co., Aichi, Japan) set to endodontic treatment was indicated.
power 3 was placed 1 mm short of the working length (WL)
After the patient underwent anesthetic procedures, cavity
and first activated with 5 mL 2.5% NaOCl followed by
access, absolute isolation, and initial instrumentation of
5 mL 17% ethylenediaminetetraacetic acid (EDTA) and
the root canal were performed using nickel‑titanium hand
finally with 5 mL 2.5% NaOCl solution. All solutions were
files (Dentsply Maillefer, Ballaigues, Switzerland). The root
renewed and activated by three cycles of 20 s. After drying
canal was irrigated with 2.5% NaOCl during mechanical
preparation. During this stage, there was profuse bleeding
within the canal. The canal was irrigated with saline solution,
and an intracanal medication, which was a combination of 2%
chlorhexidine gel and calcium hydroxide, was manipulated
and inserted using lentulo spirals. The tooth was sealed
coronally with coltosol (Coltene Whaledent) and composite

a b

a b c

c d
Figure 1: External cervical resorption of maxillary left central incisor. d e f
(a) Preoperative periapical radiography. (b) Cone beam computed Figure 2: Surgical access of external cervical resorption: (a) Clinical
tomography. (c) Endodontic treatment. (d) 18 months follow‑up: aspects. (b) Incision. (c) Surgical exposure of resorption. (d) Restoration
Radiographic aspects with glass ionomer. (e and f) Clinical aspects after suture

128 European Journal of General Dentistry ¦ Volume 6 ¦ Issue 3 ¦ September-December 2017

 Lima, et al.: Management of root resorption in traumatized teeth

techniques have been shown to reveal limited information on

the true extent and nature of the resorptive lesion. Thus, CBCT
has become an important diagnostic tool for the detection of
resorption because it provides 3D imaging.[10-12] Many authors
have emphasized the importance of CBCT for the diagnosis and
determination of the treatment plan for root resorption. Recent
studies[5,12,13] have reported the superior accuracy of CBCT
a b
in the detection and location of root resorption compared to
periapical radiographs. A CBCT scan was requested for both
the cases described in this study. In case 1, the use of CBCT
helped to determine the position and depth in relation to the
root canal and ultimately, the restorability of the tooth. In case
2, no communication was observed between the root canal
and periodontal ligament, ensuring the determination of an
c d appropriate treatment plan.
Figure 3: Internal inflammatory resorption of maxillary left central incisor.
(a) Preoperative periapical radiography. (b) Cone beam computed Treatment of external cervical resorption depends on the
tomography. (c) Endodontic treatment. (d) 24 months follow‑up: extent of resorption. Heithersay [7] divided this condition
Radiographic aspects into four classes according to the degree of damage to
the mineralized tissues. Class I corresponds to a small,
resin (Filtek, 3M Espe). We recommended that the patient invasive resorptive lesion near the cervical area with
undergo CBCT to assess the communication between the shallow penetration into the dentin; class II corresponds
resorption and periodontal ligament, which would have justify to a well‑defined resorptive lesion close to the coronal
the profuse bleeding. pulp chamber with little or no extension into the radicular
The patient returned after 15 days, and he reported no symptoms. dentin; class III corresponds to a resorptive defect involving
The images revealed that the resorption had well‑defined limits the coronal third of the root; and class IV corresponds to a
with the absence of communication [Figure 3b]. Following resorptive defect extending beyond the cervical third of the
anesthetization of the patient, the restoration was removed root. In class I and II resorptions, the canal can be preserved
and the tooth was isolated. The intracanal medication was and resorption can be restored with composite resin or glass
removed with profuse saline irrigation. Odontometry was ionomer cement. The prognosis of class III and IV resorptions
performed using an electronic apex locator (Novapex, Forum is more uncertain because the treatment is more complex in
Technologies) and was confirmed by hand files. Instrumentation these cases.[14,15] In clinical case 1, cervical resorption was
was completed with ProTaper rotary instruments (Dentsply classified as type II after examining the CBCT; however,
Maillefer). An Irrisonic E1 (20/.01) tip (Helse Industria e endodontic treatment was performed because the tooth did
Comercio) fitted to an ENAC ultrasonic handpiece (Osada not respond to pulp sensitivity tests. After surgery, resin
Electric) set to power 3 was placed 1 mm short of the WL modified glass ionomer cement was selected as the material
and first activated with 5 mL 2.5% NaOCl followed by 5 mL for sealing the resorbed area, as proposed by Heithersay.[9]
17% EDTA and finally with 5 mL 2.5% NaOCl solution. This cement is an adhesive biocompatible restorative material
All solutions were renewed and activated by 3 cycles of used in dentistry. It has favorable physical properties similar
20 s. Subsequently, filling was performed using gutta‑percha to those of resin cements while retaining the basic features
thermoplastification and AH Plus sealer (Dentsply Maillefer). of the conventional glass ionomer cement.[16]
After a follow‑up of 24 months, the patient reported no Another material that can be used in the treatment of external
symptoms and examination revealed the lack of periapical cervical resorption is MTA which presents biocompatibility,
changes [Figure 3c and d]. good sealing, and ability to form cement.[7] However, this
material is more indicated in nonesthetic areas as it can cause
Discussion tooth discoloration.[16] More recently, biodentine has also been
Pathological root resorption leads to irreversible loss of tooth recommended. Biodentine is a new tricalcium silicate‑based
structure, and progression of resorption can cause tooth loss if dentin replacement and repair material which has been
the process is not stopped.[2,3] The main etiological factors of shown to possess similar biocompatibility and sealability as
resorption are related to dental trauma, orthodontic movement, MTA.[17,18] However, information on its use in resorptive defect
internal bleaching, periodontal treatment, and idiopathic is limited and long‑term color stability of biodentine remains
causes.[2,3] In this report, the two patients presented with a unproven.[17,18]
history of trauma in their anterior teeth.
IR is characterized by intraradicular destruction of the
Diagnosis of root resorption depends on careful clinical and dentin and dentinal tubules because of clastic cell action;[2,3]
radiographic analysis. Moreover, conventional radiographic this type of resorption can be confused with external

European Journal of General Dentistry ¦ Volume 6 ¦ Issue 3 ¦ September-December 2017 129

 Lima, et al.: Management of root resorption in traumatized teeth

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