25601273.pptx resoption in endodontic work

Resorption – Dr. Nithin Mathew
Internal Resorption
• Definition:
• Internal resorption is an unusual form of tooth resorption that begins centrally
within the tooth, apparently initiated in most cases by a peculiar inflammation of
the pulp
• Internal Root Resorption
• Internal surface resorption
• Internal infection related root resorption
• Internal replacement resorption
[ Shafer ]
[ Ingle ]

Internal Resorption
Clinical Features:
• Asymptomatic until it has perforated and become necrotic
• Detected through routine radiographs
• Pain : lesion perforates and tissue exposed to oral fluids
• Can be found in all areas of root but most commonly found in cervical region
• Common in maxillary central incisors
• Usually single tooth but can involve multiple teeth
• Granulation tissue manifests as a “Pink Spot”
[ Ingle ]

INTERNAL RESORPTION
113
Internal Surface Resorption

Etiology:
• Found in areas where revascularisation occurs
• Fracture lines of root fracture
• Apical part of root canal of luxated teeth undergoing revascularisation
Pathogenesis:
• Osteoclastic activity is part of the process along with formation of granulation
tissue
[ Ingle ]

Radiographic Findings:
• Appears to be a temporary widening of root canal
Endodontic Implications:
• Resorption process - is a sign of progressing pulp healing.
• Any endodontic intervention may arrest this process.
Treatment:
• No treatment except periodic observation
[ Ingle ]

Transient Apical Internal Resorption
• Another form of trauma induced non-infective root resorption identified by Andreasen in 1986.
• Resorption follow luxation injuries
• Recognized by a confined periapical radiolucency which resolves within a few months.
• There may be associated colour change due to intra-pulpal haemorrhage.
• This resolve spontaneously if revascularisation to the coronal pulp chamber occurs
[ Australian Dental Journal Endodontic 2007 ]

Transient Apical Internal Resorption
• In the longer term, (transient process), the internally resorbed apex will close uneventfully.
Radiograph taken 1 year after the original
trauma shows resolution of the apical
internal resorption and no other signs of
periradicular pathosis

INTERNAL RESORPTION
118
Internal Infection Related Resorption

Internal Infection Related Root Resorption
Etiology:
• Coronal to the resorption site in pulp, necrotic infected tissue is
found.
• Resorption site – represents resorbing granulation tissue
interposed between healthy & diseased pulp
Pathogenesis:
• Resorption process – gradually expand – leading to fracture of
root
119
[ Ingle ]

Treatment:
• Endodontic treatment is appropriate
• Require technique that allows management of resorbed area
• Thermoplastic obturation
[ Ingle ]

• Internal inflammatory resorption may be classified according to location :
• Apical
• Intraradicular
Apical :
• Study showed that 74.7 % of teeth with periapical lesions had varying
degrees of apical internal resorption.
• Radiographically, apical internal resorption is difficult to diagnose when
the resorptions are of the lower grades.
[ Int Endod J 2004;37 ]

Intraradicular :
• Internal resorption fully contained within an intact root
• Round or oval shaped radiolucencies contained within the tooth root

Treatment:
• Defect not perforated the root to the periodontal ligament :
• Obturation with warm guttapercha technique.
• Defect perforated the root below bone level :
• A hard tissue barrier can be produced with long-term calcium hydroxide treatment,
after which obturation is carried out.
• Defect perforates coronal to the epithelial attachment or if an extremely large perforation is
present :
• A surgical approach is required to seal the perforation.
[ Cohen ]

Treatment (Apical) :
• Extend instrumentation only to the position of the resorption.
• With the removal of micro-organisms followed by root canal filling,
hard tissue repair will occur in the resorbed apical region.
• Treatment to the position of the resorption help in achieving biological
repair of the resorbed apex.
Radiograph taken 2 years later showing
periradicular repair and control of the root
resorption.

Treatment (Intraradicular) :
• Preparation of the canal to the apical foramen.
• Particular emphasis on irrigation and ultrasonication ( resorbed area is
cleansed thoroughly ).
• Thermoplastic obturation of canal.

INTERNAL RESORPTION
126
Internal Replacement Resorption

Etiology:
• Damage to pulp tissue usually related to trauma.
• When damaged pulp tissue replaced as a part of healing process – tissue
metaplasia occurs – formation of bone tissue in pulp canal
• Damaged pulp tissue – replaced with an ingrowth of new tissue, includes
bone derived cells.
Pathogenesis:
• Root will gradually be replaced with bone
• In some cases bone replacement will spontaneously arrest
[ Ingle ]

Clinical Findings:
• Teeth asymptomatic
• If ankylosis develop – teeth gradually develop infraocclusion
Radiographic Findings:
• A dissecting resorptive area- seen in root canal initially
• Root canal appears intact
[ Ingle ]

Treatment :
• Pulpectomy, curettage of the resorptive defect and root filling
• Generally control the resorptive process as soon as possible

Treatment :
In extensive cases:
• Resorptive tissue may communicate with the periodontal ligament
• Pulpectomy supplemented by the careful topical application of 90%
aqueous trichloracetic acid to the defect
• This inactivate any communicating resorptive tissue
• Insert conventional root filling
• In communicating lesions - MTA may be used to seal the defect prior to
the placement of a root filling.

Physiologic Root Resorption
• Entirely normal process
• Happens with the timely loss of deciduous teeth
• Occurs during the exfoliation of the primary dentition and eruption of
permanent successors
• Occurs in three separate phases
• Active
• Partial
• Reparative

Pathologic Resorption due to Systemic Causes
• Resorption occurs at the apex of several teeth and is bilateral
• Hypo parathyroidism
• Hyper parathyroidism
• Calcinosis
• Turner’s syndrome
• Paget’s disease
• Following radiotherapy
• Renal distrophy
• Genetic factors

Difference b/w Internal & External Resorption
INTERNAL EXTERNAL
• Margins are smooth & clearly defined • Borders irregular & ill defined
• Root canal walls appear to balloon out
• Outline of root canal distorted • Outline of root canal is normal
• Root canal & resorptive defect appear
continuous
• Root canal is seen running through the defect
• Radiolucency confined to root (does not
involve bone)
• Almost always accompanied by resorption of
bone
• Bone lesion seen-only if resorption perforate
tooth
• Radiolucency appear in root and adjacent bone
• Lesion appear close to root canal in different
angulations
• Lesion moves away from canal as angulation
changes
Radiographic Features

Pharmacological Management of Inflammatory Response
• Drugs that affects osteoclasts present at the site of resorption :
• Tetracyclines
• Sustained antimicrobial effect
• Anti-resorptive properties
• Direct inhibitory effect on osteoclasts and collagenase
• Significantly more cemental healing
• Drugs that affect the recruitment of osteoclasts to the injury site :
• Glucocorticoids
• Topical dexamethasone was found to be useful while systemic usage was not
• Bisphoshonates
• Alendronate
• Amino acids
• Taurine

Pharmacological Management of Inflammatory Response
• Combination of the two types of drugs
• Synergistic effect on the inhibition of root resorption
• Ledermix
• A drug combining tetracycline and corticosteroids

ART - Antiresorptive Regenerative Therapy (Pohl et al 2005)
• Comprises a combination of different treatment strategies for a synergistic effect :
• Local application of a glucocorticoid
• Systemic and local application of Tetracyclines
• Use of Enamel Matrix Derivative (EMD) e.g. Emdogain
• Emdogain (Enamel Matrix Protein)
•Makes the root more resistant to resorption
•Stimulates the formation of new periodontal ligament from the socket

AAE Guidelines (Management of External Root Resorption)
Unfavorable:
Structural integrity of the tooth or
root is compromised
• There are deep probing depths
associated with the resorptive
defect
• The defect is not accessible for
repair surgically
Favorable:
Minimal loss of tooth structure
• Located cervically but above
the crestal bone
• The lesion
repair
is accessible for
• Apical
associated
root
with
resorption
a tooth
exhibiting pulp necrosis and
apical pathosis
Questionable:
Minimal impact on restorability of
tooth
• Crown lengthening or
orthodontic root extrusion may
be required
• The pulp may be vital or necrotic

Conclusion
• The diagnosis of dental resorptions and an understanding of the underlying pathosis is critical to
clinical management.
• Most infection related resorption respond well to endodontic treatment.
• Early diagnosis and prompt treatment are the key factors which determine the success of the
treatment.

References
• Ingle
• Cohen
• Seltzer & Bender
• Weine
• Gulabiwala
• Harty
• Nisha Garg

25601273.pptx resoption in endodontic work

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