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: [email protected] 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) Scan this QR code to access article. 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 Downloaded from www.jrdindia.org 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. - 10 - 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. Downloaded from www.jrdindia.org the resorptive cavity will ill be removed later (Figure 4).As the lesion was clinically cli not accessible, a - 11 - 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 Downloaded from www.jrdindia.org removed. No - 12 - 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 Downloaded from www.jrdindia.org 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 - 13 - 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 Downloaded from www.jrdindia.org and - 14 - 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. 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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 - 16 -
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