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Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 146-149

Diagnosis of external invasive cervical tooth resorption and its management using biodentine

Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, BHU, Varanasi, Uttar Pradesh, India

Date of Submission03-Apr-2022
Date of Acceptance26-Jul-2022
Date of Web Publication2-Sep-2022

Correspondence Address:
Jyoti Yadav
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, BHU, Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jigims.jigims_20_22

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Invasive cervical resorption (ICR) is a rare advancing and expansionist kind of external tooth resorption that commences within the cervical region. The treatment goal must be a complete elimination of all resorbing tissues and restoration of the resorptive defect with the placement of an acceptable filling material to achieve desired function and esthetics. The successful outcome of treatment depends on early detection and proper diagnosis. This article shows the detection and management of maxillary right central incisor in a 24-year-old female diagnosed with ICR, using biodentine and resin-modified glass ionomer cement.

Keywords: Biodentine, cone-beam computed tomography, external cervical resorption, resin-modified glass ionomer cement

How to cite this article:
Baranwal HC, Yadav J, Rani P, Samad S, Ayubi A. Diagnosis of external invasive cervical tooth resorption and its management using biodentine. J Indira Gandhi Inst Med Sci 2022;8:146-9

How to cite this URL:
Baranwal HC, Yadav J, Rani P, Samad S, Ayubi A. Diagnosis of external invasive cervical tooth resorption and its management using biodentine. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2023 Mar 27];8:146-9. Available from: http://www.jigims.co.in/text.asp?2022/8/2/146/355315

  Introduction Top

External tooth resorption known as invasive cervical resorption (ICR) is a rare, sneaky, and typically aggressive form of tooth resorption that can occur in any tooth of permanent dentition.[1] ICR is defined as “a confined resorptive process that originates on the surface of root below the epithelial attachment and coronal aspect of supporting the alveolar process, specifically, the zone of the connective tissue attachment.” Trauma, orthodontic treatment, orthognathic and dentoalveolar surgery, intracoronal bleaching, and surgical procedures have been listed as potential predisposing factors for ICR.[2] External cervical resorption (ECR) is mostly detected in maxillary central incisor teeth followed by a maxillary canine, maxillary lateral incisor, mandibular first molar, and maxillary first molar teeth.[3] The distribution of the resorption lesion is also a pathognomonic feature of ECR.[4] Pathological sections have provided important references for understanding the cellular as well as tissue constituent of the resorption lesion.[5]

Tronstad and Trope[2],[6] hypothesized a dual cause: injury and stimulation by sulcular microorganisms in the adjacent marginal tissues. Heithersay has stated cases in the literature, which showed that the root resorption process is not a result of inflammation but due to invasion of resorption lacuna by microorganisms at a later stage. Heithersay[1] further classified this type of resorption based on its extent into four classes were, Class I – a tiny resorptive lesion infiltrating the cervical area and penetrating the dentinal structure only superficially, Class II – a well-defined resorptive defect penetrating close to the coronal portion of the pulp, Class III – the resorptive lesion extends to the coronal third of the root, and Class IV – a big and deep resorptive defect that extends beyond the coronal third of the root.

ICR is usually asymptomatic and often detected when the affected tooth displays a pink discoloration in the cervical region of the crown or on routine radiographic examination exhibiting an irregular radiolucency with ragged margins or “motheaten” appearance.[1],[6] Cessation of the resorptive process, removal of resorptive tissues, and restoration of the lost tooth structure will lead to successful management of ICR. Various materials have been promoted to seal the resorptive defect such as mineral trioxide aggregate (MTA), glass-ionomer cement, and calcium-enriched mixture.[7] A new bioactive cement, biodentine can be a useful option since its properties are comparable with that of natural dentin making it a dentin substitute.

This case report describes the treatment of the maxillary right central incisor, diagnosed with an invasive ECR surgically using biodentine and resin-modified glass ionomer cement (RMGIC).

  Case Report Top

A 24-year-old female patient presented to the department of conservative dentistry and endodontics with the chief complaint of discolored upper front teeth along with pus discharge from this region. The medical history of the patient was noncontributory. Past dental history revealed that she had undergone trauma 9 years ago and her teeth remained untreated.

Intraoral examination showed discolored maxillary right central, lateral, and left central incisors. Maxillary right central incisor (tooth #11) showed grayish pink discoloration of the crown and pus discharge from the marginal gingiva on the labial side in relation to this tooth [Figure 1]a. On probing, bleeding was present and a rough surface was detected on the labial side of tooth # 11. The teeth #11, #12, and #21 showed a negative response to the pulp vitality test. On radiographic examination, irregular radiolucency in the cervical area and coronal third of the root were present and normal periradicular and periodontal ligament status was seen in relation to tooth #11, a small periapical radiolucency seen wrt to tooth #12 and pulp canal obliteration with a widening of periodontal space at root apex seen in relation to tooth #21 [Figure 1]b. Cone-beam computed tomography (CBCT) images confirmed the presence of external cervical root resorption on a buccal surface extending to the middle third of the root with perforation of the root canal wall along with the involvement of mesial and distal surface of the cervical root region #11 [Figure 1]c and [Figure 1]d. The diagnosis was made Class IV invasive external cervical root resorption with pulp necrosis in tooth #11, pulp necrosis with chronic periapical abscess for tooth #12, and calcific metamorphosis with asymptomatic apical periodontitis in tooth #21.
Figure 1: (a) Preoperative intraoral photograph showing discolored teeth #11, #12, and #21; (b) Preoperative radiograph of tooth #11 showed irregular radiolucency at the cervical region; (c and d) CBCT axial and sagittal view showing the extent of resorption, pulp involvement, and pattern of bone loss. CBCT: Cone-beam computed tomography

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Written informed consent was obtained from the patient. A rubber dam was placed and an access cavity was prepared on the lingual surface of teeth #11 and #12. After working length determination with #20, K-file cleaning and shaping of root canal were performed with the hand K-file (Dentsply) in teeth #11 and #12. Irrigation was performed with normal saline only in tooth #11, due to the presence of the root canal perforation. The tooth was not obturated in the first visit since proper cleaning and debridement of the root canal system before complete removal of resorptive tissue and sealing the perforation area was not possible. A calcium hydroxide dressing was placed for 1 week.

At the second visit after administration of local anesthesia, a full mucoperiosteal flap was reflected to expose the resorptive lesion. Granulomatous tissue was excavated from the resorptive area using a hand excavator and resorptive channels were cleaned with ultrasonic (Orikam Eighteeth Ultra X), under magnification with loup (Zumax Medical Co, Ltd.) [Figure 2]a. The cavity was treated with 90% aqueous solution of trichloroacetic acid. After removing any undermined dentin or enamel with a bur in a high-speed handpiece and drying the prepared cavity, a tapered gutta-percha was placed in the canal to maintain its patency during the restoration process. The resorptive area was filled with biodentine (Septodont, Saint-Maur-des-Fossés, France) and contoured properly [Figure 2]b. Biodentine was placed till the cementoenamel junction (CEJ) covered only the resorptive defect on the root surface. It was left for 15 min to achieve the initial setting and relative hardness. After the setting of biodentine was confirmed, RMGIC (GC Corporation Tokyo, Japan) was placed over the biodentine at the CEJ level [Figure 2]c. The rest of the resorptive defect over the CEJ level on the coronal aspect was restored with composite (Te-Econom Plus, Ivoclar, Vivadent) after applying a bonding agent [Figure 2]c. Finally, the flap was sutured with 40 vicryl suture material and root canal obturation was completed with the lateral condensation technique. Postoperative intraoral periapical radiograph was taken [Figure 2]d and the patient was instructed to report after a week for suture removal. On further follow-up, healing was observed at the surgical site [Figure 2]e. Later, root canal treatment was completed in tooth # 21 also. On the next visit, the crown was placed and a 9-month follow-up was done [Figure 2]f and [Figure 2]g.
Figure 2: (a) Resorptive defect after curettage and cleaning; (b) Sealing of defect with biodentine; (c) Radicular portion covered with RMGIC and coronal portion with composite; (d) Postoperative IOPA after restoration and obturation; (e) postoperative clinical view showed healing; (f) Clinical view after crown placement; (g) 9-month follow-up radiograph. RMGIC: Resin-modified glass ionomer cement, IOPA: Intraoral periapical radiograph

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  Discussion Top

The damage to the cemental layer exposing the dentin and the superimposition by bacteria remains to be the etiological factor for the development of the ICR.[1],[8] In this case, history of trauma might be the cause that had damaged the cemental layer of the tooth and led to the bacterial infection leading to inflammation and the progression of the cervical resorption.

Regarding the treatment of ICR, successful management of each case must be linked to the etiology. A radiographic evaluation is essential for the diagnosis of ICR and distinguishing this lesion from internal root resorption. The use of CBCT is an important diagnostic tool in this regard. This imaging technique may confirm the real extent of resorption and its possibility of communication with the pulpal and periodontal space.[9] Several authors have proposed different treatment approaches for the treatment of ICR, but the basic aim is the complete removal of resorptive tissue and the restoration of the defect area.[10],[11] The present case describes an invasive cervical resorptive defect in which the tooth shows a sign of pulpal infection and requires root canal treatment followed by sealing the resorptive area with biodentine using surgical intervention. During the debridement of the resorptive lacuna, the use of chemical escharotic agents, such as trichloroacetic acid, improves the possibility of completely eliminating resorbing cells, which penetrate into the deeper parts of the defect and enhance the visualization of the defect.[12] In this case, the resorptive area was debrided with ultrasonic tips and alternating solutions of 5% sodium hypochlorite and 17% ethylenediaminetetraacetic acid.[13] Surgical treatment of varying degrees of ICR usually involves periodontal flap reflection, curettage, granulation tissue removal, and restoration of the defect with suitable material, such as MTA, resin-modified glass ionomer cement (GIC), calcium-enriched mixture (CEM), biodentine, and repositioning the flap to its original position.

Here, after surgery, biodentine was selected as the material for the restoration of the resorbed area over the root surface, as it can be placed in permanent and close contact with periradicular tissue due to its bioactivity and biocompatibility. Dentin-like mechanical properties advocate its use as a dentin substitute on crowns and roots. Compared with other bioactive materials such as MTA, biodentine handles easily and needs much less time for setting. Its property to release calcium ions and enhance the alkaline environment makes biodentine more conducive to osteoblastic activity. Furthermore, calcium and hydroxide ions stimulate the release of pyrophosphatase, alkaline phosphatase, and bone morphogenetic protein-2, which favors the regeneration and mineralization process.[14] Teeth treated with white MTA exhibited discoloration, whereas those treated with biodentine maintained color stability. RMGIC uses over biodentine because it is less soluble than biodentine and it provides more strength to the root.

  Conclusion Top

The successful outcome and long-term retention of the ICR depend on the proper diagnosis, case selection, and treatment plan. Although this case report presents a favorable outcome, further studies are encouraged to support the use of biodentine to fill external ICR defects.

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

Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int 1999;30:27-37.  Back to cited text no. 1
Tronstad L. Root resorption-Etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988;4:241-52.  Back to cited text no. 2
Priyalakshmi S, Ranjan M. Review on biodentine-A bioactive dentin substitute. J Dent Med Sci 2014;13:13-7.  Back to cited text no. 3
Patel J, Beddis HP. How to assess and manage external cervical resorption. Br Dent J 2019;227:695-701.  Back to cited text no. 4
Jebril A, Aljamani S, Jarad F. The surgical management of external cervical resorption: A retrospective observational study of treatment outcomes and classifications. J Endod 2020;46:778-85.  Back to cited text no. 5
Trope M. Root resorption of dental and traumatic origin: Classification based on etiology. Pract Periodontics Aesthet Dent 1998;10:515-22.  Back to cited text no. 6
Jeng PY, Lin LD, Chang SH, Lee YL, Wang CY, Jeng JH, et al. Invasive Cervical Resorption-Distribution, Potential Predisposing Factors, and Clinical Characteristics. J Endod 2020;46:475-82.  Back to cited text no. 7
Abbott PV. Prevention and management of external inflammatory resorption following trauma to teeth. Aust Dent J 2016;61 Suppl 1:82-94.  Back to cited text no. 8
Vasconcelos Kde F, Nejaim Y, Haiter Neto F, Bóscolo FN. Diagnosis of invasive cervical resorption by using cone beam computed tomography: Report of two cases. Braz Dent J 2012;23:602-7.  Back to cited text no. 9
Ikhar A, Thakur N, Patel A, Bhede R, Patil P, Gupta S. Management of external invasive cervical resorption tooth with mineral trioxide aggregate: A case report. Case Rep Med 2013;2013:139801. [doi: 10.1155/2013/139801].  Back to cited text no. 10
Subramanyappa SK, Parthasarathy B, Manjegowda PG, Rajeev S. Management of perforating invasive cervical resorption: Two case reports. J Indian Acad Oral Med Radiol 2012;24:346-9.  Back to cited text no. 11
  [Full text]  
Heithersay GS. Treatment of invasive cervical resorption: An analysis of results using topical application of trichloracetic acid, curettage, and restoration. Quintessence Int 1999;30:96-110.  Back to cited text no. 12
Cohen S, Hargreaves KM, Berman LH. Cohen's Pathways of the Pulp. 10th ed. St. Louis, MO: Mosby; 2010. p. 605.  Back to cited text no. 13
Gandolfi MG, Siboni F, Polimeni A, Bossù M, Riccitiello F, Rengo S, et al. In vitro screening of the apatite-forming ability, biointerctivity and physical properties of a tricalcium silicate material for endodontics and restorative dentistry. Dent J 2013;1:41-60.  Back to cited text no. 14


  [Figure 1], [Figure 2]


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