VERIFIABLE CPD PAPER

Endodontics CLINICAL

The ins and outs of root resorption

Shanon Patel*1,2 and Navid Saberi1,3

Key points
Suggests the phenomenon of root resorption is
not well understood, especially in general practice,
and as a result many lesions are diagnosed and
treated incorrectly.
Highlights that previous articles in this field are
either not systematic or lack current evidence-based
background.
Presents a simple classification and systematic
discussion that will not only help GDPs manage
these defects effectively, but also provide students,
specialist trainees, teachers and specialists with a
concise account.

Root resorption is a poorly understood phenomenon and is often misdiagnosed and, as a result, inappropriately treated. The
aim of this paper is to provide a practical guide for diagnosis of root resorption lesions using a simple classification, and to
describe the principles of management of these resorptive defects in everyday practice.

Introduction Fig. 1 The classification of dental resorptive lesions based on their location in relation
to the root surface, and then sub-categorised according to pathogenesis
Root resorption is the non-bacterial destruc-
tion of the mineralised cementum or dentine
due to the interaction of clastic cells and dental Root Resorption
hard and soft tissues.1-3
In the adult dentition root resorption is
caused by osteoclast-like multi or occasion-
Internal External
ally mononucleated cells called odontoclasts.
Roots are usually protected against external
and internal root resorption by unmineralised
organic cementoid and predentin, respectively, Inflammatory Inflammatory
and therefore do not undergo resorption in
normal circumstances.2,4 This is due to the Replacement Replacement
inability of the clastic cells to adhere to unmin-
eralised surfaces.2,4 Cervical
Resorption of permanent teeth is pathologic
in nature and therefore undesirable.5 However, Surface
in the primary dentition it is desirable as this
physiologic root resorption aids exfoliation Transient apical breakdown
of the deciduous tooth and thus facilitates
eruption of the permanent successor.
Root resorption occurs in three stages;
initiation, resorption and repair.6 The process undetected clinically. Once initiated, if the There are many different classifications of the
of resorption may be self-limiting and go initial surface resorptive process is sustained, dental resorptive lesions based on histology,
for example by infection and/or pressure, dental aetiology or origin in the literature.1–3,8,9 Root
1
Department of Conservative Dentistry, King’s College hard tissue destruction will continue and tooth resorption is a poorly understood phenom-
London Dental Institute, Guy’s Dental Hospital, Tower tissue loss may occur. This may result in the enon, it is often misdiagnosed and is inappro-
Wing, London; 2Specialist practice, London; 3Specialist
Practice, Brighton tooth becoming unsalvageable. priately treated.
*Correspondence to: Dr Shanon Patel Detailed accounts of the pathogenesis of The aim of this paper is firstly, to provide a
Email: shanonpatel@gmail.com
the dental resorptive lesions have not been practical guide for diagnosis of root resorption
Refereed Paper. Accepted 5 March 2018 discussed here as they would be beyond the lesions using a simple classification (Fig. 1),
DOI: 10.1038/sj.bdj.2018.3 52
scope of this paper.7 and secondly to describe the principles of

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Table 1 Characteristic key features of root resorption

Internal External
Resorption Type
Inflammatory Replacement Inflammatory Replacement Cervical Surface
Discolouration, Discolouration,
symptoms of Symptoms of Discolouration, May exhibit a metallic Probable periodontal
Clinical finding irreversible pulpitis irreversible pulpitis symptoms of apical percussion sound. defect, symptoms of (ir) None
and/or apical and/or apical periodontitis Mobility not expected reversible pulpitis
periodontitis periodontitis
Pink spot (rare), or Pink spot (rare), or Healthy, or sign +/- pink spot, or sign
Clinical
sign of pulpitis / sign of pulpitis / of pulpitis / apical Healthy of pulpitis / apical Healthy
appearance
apical periodontitis. apical periodontitis. periodontitis. periodontitis.
Adjacent to
Cervical third initially but impacted tooth,
can be seen in mid and cyst or tumour.
Location on root Anywhere Anywhere Anywhere Anywhere
apical third in advanced Apical in
cases orthodontically
treated teeth
Maybe +ve in Maybe +ve in Usually +ve ,
partially vital cases, partially vital cases,
Pulp sensitivity -ve +ve –ve in advanced necrotic +ve
or -ve in advance or -ve in advance
necrotic cases necrotic cases cases

(A)symmetrical
Symmetrical oval Oval shaped Asymmetrical bowl Asymmetrical bony
radiolucent (early), or Blunted root apex.
Radiological shaped (ballooning) enlargement of root shaped periradicular replacement of root
radiopaque (advanced) Asymmetrical loss
appearance enlargement of root canal with cloudy and/ or periapical surface and loss of
appereance. Lesion of root
canal or mottled canal wall radiolucencies PDL space
moves on parallax views
Intact in early EIR,
Canal expands into Canal expands into Intact, but perforation in
Root canal perforation in Intact Intact
lesions lesions advanced cases
advanced cases

management of these resorptive defects in
everyday practice (Table 1).
Internal root resorption:
Internal inflammatory resorption (IIR)
This type of resorption may occur as a result
of damage to the predentine either by trauma
due to physical or chemical irritation or by
bacterial infection in chronic pulpal inflam-
mation. In active progressive IIR lesions, the
root canal coronal to the resorptive lesion will
typically be necrotic, while apically the pulp is
vital providing nutrients to the odontoclasts
allowing the resorptive lesion to progress.
However, if the tooth loses vitality, resorption
will cease to progress.1,5,8
Clinical signs and symptoms are normally
diagnosed in advanced lesions. Teeth with IIR
are usually asymptomatic but because these
teeth are partially vital during resorptive
lesion expansion, they may exhibit signs of
reversible or irreversible pulpitis. In advanced
cases, that is, with infected necrotic root canal
systems, there may be symptoms and/or signs
of periapical periodontitis (for example, discol-
ouration, sinus, tenderness to palpation and/
or percussion).
Diagnosis is usually made radiographically.
Historically, the radiographic appearance of
these lesions has been described as a radio-
lucent symmetrical round or oval ballooning
out of the root canal wall. However, in reality
the radiographic appearance of these lesions
may deviate from the above descriptions and
in many cases, does not follow these rigid por-
trayals commonly described in review papers
(Fig. 2).7,10 Although parallax technique may
be used to confirm the position and nature of
the lesion, IIR may still be misdiagnosed as
external cervical resorption in multi-rooted
teeth as the root canal of an unaffected tooth
may be superimposed over the affected root,
thus giving the appearance of external cervical
resorption.10
Where management of IIR is being con-
sidered, a small field of view, high resolution
cone beam computed tomography (CBCT) is
recommended to appreciate the exact nature,
location and extent of the IIR and the presence
of a perforation.8,11 These factors may have an
impact on the restorability and/or the manage-
ment of the case.
Due to the granulomatous nature of the
lesion, profuse bleeding from the root canal
is frequently observed upon accessing the
canal system. This will cease as soon as the
pulp and granulation tissue have been com-
pletely removed. Due to the complex nature
of the resorptive defect, energised irrigation
and inter-appointment medication have been
recommended.11,12
Due to the irregular nature of IIR and the
root canal space, it is desirable to obturate the
root canal with a thermoplasticised root filling
to ensure optimum adaptation and compac-
tion. In cases where IIR has perforated the root
it may be necessary to seal the affected portion
of root canal space with a bioactive root filling
material, for example MTA or Biodentine.11
Internal replacement resorption (IRR)
This type of resorption is relatively uncommon
with an unknown aetiology. However, it is
usually associated with a history of dental
trauma, caries or periodontal infections
affecting the pulp as the main contributing
factors.7,8
Histological appearance of IRR defects
reveals the presence of metaplastic hard tissue
replacing the resorbed dentine at the periphery
of the defect, which is suggestive of active and
simultaneous resorption and replacement. This
metaplastic hard tissue resembles cementum
or osteoid-like tissues. However, detailed
pathogenesis is not fully understood.8 It has
been suggested that IRR is an attempt of IIR
to replace the damaged (resorbed) dentine.7
Clinical signs and symptoms of IRR are
indistinguishable from IIR, and is usually

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 Endodontics CLINICAL

diagnosed in advanced lesions. Teeth may be

asymptomatic, however, as the active lesions
are partially vital during the resorption phase,
they may exhibit signs of reversible or irrevers-
ible pulpitis. In infected necrotic cases, signs
and symptoms of apical periodontitis (for
example, discolouration, sinus, tenderness to
palpation and/or percussion) may be observed.
Diagnosis is made radiographically. The
resorptive defect and the adjacent root wall
usually have a cloudy and/or mottled appear-
ance due to the radiopaque inclusions of
hard tissue. The outline of the canal appears
distorted and expanded. The true nature,
position and extent of the defect can only be
accurately detected with a CBCT (Fig. 3).
The management of IRR is similar to IIR and
involves root canal treatment with energised
irrigation and obturation with thermoplasti-
cised gutta-percha. Endodontic ultrasonic tips
Fig. 2 Internal inflammatory resorption. (a) A periapical radiograph of mandibular right and may be required in order to navigate through
left central incisors with radiographic signs of IIR (red arrows); note the ballooning out of the osteoid-like hard tissue. In restorable
the root canal and relatively symmetrical nature of the defect. The margins are well-defined. but perforated lesions, a subsequent surgical
(b) The sagittal CBCT slice through the mandibular right central incisor reveals the intact approach may also be required.11
canal walls (yellow arrows) and the true dimension of the defect and root canal (red dashed
line) that cannot be appreciated on the periapical radiograph. (c, d) Axial and (e) coronal
CBCT slices through the same teeth reveal that the defects are in fact asymmetrical in nature External root resorption
(red arrows). (f) The root canals have been obturated using thermoplasticised gutta percha
and temporised for bleaching (courtesy of Dr Alan Knight, King’s College London)
External inflammatory resorption (EIR)
EIR occurs in teeth with infected necrotic root
canals as a result of caries and microleakage and
is a common finding in almost all teeth with
periapical periodontitis.1,5,7,9 These resorptive
lesions are frequently observed following severe
traumatic dental injuries (for example, avulsion
and luxation injuries). In these cases, the initial
external resorption is triggered by injury to the
root surface and the associated periodontium.
However, the progression of the lesion is largely
dictated by pulpal vitality.1,2,7,9 Consequently, if
the affected tooth does not lose its blood supply,
the osteoclastic activity will only focus on the
repair of the damaged outer root surface and
the resorption will be self-limiting, similar to
what is seen in transient apical breakdown
(which will be discussed in more detail later
in the paper). However, if the root canal space
becomes infected, bacterial toxins may advance
via dentinal tubules to the resorption area,
resulting in the progression of EIR.
Fig. 3 Internal replacement resorption. (a, b) Periapical radiographs of a maxillary left Clinical signs and symptoms will be similar
central incisor with radiographic signs of IRR; note the symmetrical nature of the defect, to those of periapical periodontitis, for
which remains centred with the parallax view, and the radioopaque nature of its coronal example, the tooth will be non-responsive to
aspect (c) CBCT slices through the same tooth reveals a calcified tissue in the coronal part sensibility testing and tender to percussion
of the lesion. (d, e) Obturated tooth and a 2-year review radiograph demonstrating the
and/or palpation.
irregular borders of the defect that have been obturated with thermoplastiicised gutta
percha. Reproduced from Patel S, Ricucci D, Durak C, Tay F. Internal root resorption: a
The roots may appear shorter than normally
review. J Endod 2010; 36: 1107-1121, Elsevier expected and/or have ragged root ends, and
will have apical radiolucencies adjacent to the

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 CLINICAL Endodontics

root-end. EIR associated with dental trauma

will usually appear as radiolucent crater shaped
indentations on the root surface with adjacent
periradicular radiolucencies. The root canal
outline will be visible indicating the resorption
lesion is external to the root canal. Due to the
two-dimensional nature of conventional radio-
graphs EIR will only be detected if it is located
on the proximal aspects of the root; resorptive
defects on, or extending to the buccal/palatal
aspect of the root will not be detected (Fig. 4).
In some instances, a CBCT examination
of the tooth may be indicated to confirm the
nature of the resorptive lesion, that is, the true
Fig. 4 External inflammatory resorption. (a) A periapical radiograph of a maxillary left
central incisor tooth showing a well-circumscribed and round periapical radiolucency. The extent and dimension of the lesion, the number
tooth has been root treated with what appears to be gutta-percha. However, the root filling of sites affected along the root and whether
lacks adequate length, width and density. During non-surgical root canal retreatment, there is a root wall perforation. This informa-
the working length could not be reliably established with the electronic apex locator. (b) tion is essential when considering endodontic
Sagittal CBCT reconstructed image through the same tooth revealed substantial loss of treatment of these cases (Fig. 5).
buccal root structure from the coronal third to the apex (yellow arrow). In addition, there Root canal treatment is indicated in restor-
was significant periapical and buccal cortical bone loss. This loss of root structure could
able teeth and will arrest the resorptive process
lead to major complications as a result of a hypochlorite accident if the defect had not been
detected. (c) The extracted tooth and associated defect and therefore prevent further damage.

External replacement resorption

(ERR)
These types of resorptive lesions appear as a result
of severe luxation and avulsion injuries.5,13,14
Depending on the nature of the injury, the peri-
odontal ligament may tear, become crushed and/
or degenerate due to desiccation resulting in the
periodontal ligament cells undergoing necrosis
and, together with cementum and dentine,
become resorbed via osteoclastic action and
replaced with alveolar bone laid down by osteo-
blasts as part of the repair process. The osteoblas-
tic activity may then gradually replace the entire
radicular dentine with bone in the process of
remodelling.1,5,15 ERR may be self-limiting and/
or localised.
It has been reported that when ERR covers
more than 20% of root surface the tooth
will lose its physiologic mobility which may
result in a high-pitched metallic sound to
percussion.5,16
The tooth may appear infra-occluded in devel-
oping dentition. As ERR is external in nature, the
tooth should respond to sensibility testing albeit
with delay if there is tertiary dentine formation.
However, lack of response to sensibility testing in
Fig. 5 External inflammatory resorption. (a, b, c) A series of periapical radiographs revealing the absence of other clinical signs and symptoms
a classic saucer-shaped excavation on the distal aspect of the maxillary left central incisor of endodontic infection, is not an indication for
associated with EIR (red arrow) and the ballooning out of the root canal and a symmetrical
endodontic treatment.
defect in the maxillary left lateral incisor affected by IIR (yellow arrows). (d, e, f) Sagittal CBCT
Conventional radiographic examination will
slices of the same teeth reveal the extent of EIR and the degree of external root wall destruction
on the central incisor (red arrows). CBCT slices also reveal the destruction caused by IIR on the reveal the lack of periodontal ligament space
lateral incisor (yellow arrow). (g, h, i) Axial and (j, k, l) coronal slices reveal and confirm the true only in proximal areas as the affected root
nature of the EIR (red arrows) and IIR (yellow arrows) and confirm the diagnosis surface in the buccal and labial aspects cannot
be assessed using conventional radiographs. A

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 Endodontics CLINICAL

the expression of bacteria-induced toll-like

receptors in ECR lesions appears to support a
bacterial aetiology.24
The aetiology of ECR remains unclear.5,20,25
However, several aetiological factors have been
reported to contribute towards the initiation of
ECR. These include trauma,2,20,25 orthodontic
treatment,20,25 periodontal treatment,2,25 den-
toalveolar surgery,25 intracoronal bleaching,25,26
playing wind instruments,27 bisphosphonate
therapy,28 Varicella Zoster virus infection29 and
idiopathic causes.20,30,31 In addition, the possi-
bility of a familial pattern and possible genetic
predisposition to ECR has been reported.32
Furthermore, a possible relationship between
ECR in humans and feline odontoclastic resorp-
tive lesions in cats has also been suggested.33
Fig. 6 External replacement resorption. (a) A periapical radiograph of the maxillary central However, there has been no strong evidence
incisors with late presentation following severe luxation injury and complicated crown root to show a ‘cause and effect’ with these suggested
fracture of the maxillary left central incisor. Note periapical radiolucency and blunting of the aetiological factors. These reported aetiological
root-ends (yellow arrows). (b) A 5-year review radiograph following root canal treatment of factors may be associated, rather than predis-
both teeth reveals direct bone replacement of the root dentine on the maxillary left central posing factors. ECR have also been observed
incisor (red brackets). Note the left central incisor has been decoronated and restored with a in unerupted teeth suggesting that ECR may, in
temporary resin bonded bridge. Note the periapical radiolucency on both teeth have healed.
some cases be idiopathic in nature.7,34–37
(c,d,e) Sagittal, axial and coronal CBCT slices through the same tooth confirm an almost
complete bony replacement of root dentine associated with ERR (green arrows) ECR lesions can be challenging to diagnose,
as individuals with ECR are usually asympto-
matic in the early stages, therefore pulpal and/
CBCT may be indicated to confirm the extent patient is old-enough for the definitive restora- or periodontal involvement may only appear
of labial and palatal ERR lesion, and therefore tive plan.17–19 at the later stage of disease progression.3,20,38 In
the prognosis of the tooth, especially in cases addition, ECR may be misdiagnosed as caries.
where follow up radiographs are showing a External cervical resorption (ECR) A pink spot in the cervical aspect of the
gradual increase in the size of ERR (Fig. 6). These resorptive defects manifest mainly in tooth is reported as a pathognomic clinical
There is no effective management for ERR the cervical region of the tooth and develop sign, however, in reality a pink spot is a rela-
apart from periodic reviewing of these cases. as a result of damage to, and/or deficiency of tively rare finding.1,21,22,39
The affected teeth may survive for years, or the subepithelial cementum.20 The aetiology of ECR is typically detected clinically when the
even decades before they become decoronated ECR is not known, however, several potential tip of a dental probe, or a periodontal scaler,
following total replacement of the root with bone. predisposing factors have been suggested.20 A engages the defect and catches the resorptive
In children and adolescents, the identi- three-stage mechanism; initiation, resorption lesion’s edges. ECR defects will feel hard and
fication and management of ERR before or (destructive) and repair, has been proposed scratchy when probed and should be dif-
during the growth spurt is of paramount for the development and progression of ECR.6 ferentiated from subgingival caries, which
importance. Teeth that undergo ERR fail to Osteoclastic cells from the adjacent peri- will give a tactile feedback of being sticky on
erupt, preventing further development of the odontium are thought to invade the exposed probing. In addition, ECR lesions often bleed
adjacent alveolar bone. This will lead to the root surface, via gaps in the cementum, and profusely when probed due to their vascu-
affected tooth becoming infra-occluded.17–19 form a fibrovascular lesion (resorption phase), larity.3 However, not all ECR lesions can be
The underdeveloped alveolar ridge associ- which may ultimately become calcified and probed and investigated in the above manner,
ated with the ankylosed tooth in these cir- develop into a fibro-osseous tissue (reparative especially if they are in the early stages of
cumstances may have a negative impact on phase).21–23 A small portion of these lesions progression and/or positioned in inaccessible
aesthetics, phonetics and function and will may arrest. However, most cervical resorption areas of the tooth or the mouth, which will be
complicate any future restorative treatment.17–19 lesions are not self-limiting and usually exhibit completely missed. As a result, radiological
Therefore, to preserve the alveolar ridge height a prolonged resorption phase.1,9 examination is of utmost importance in the
and promote its normal development, the Hithersay22 suggested that ECR lesions are diagnosis of ECR.3,5,22,23
ankylosed tooth may be electively decoronated aseptic and only become secondarily invaded In early cases, ECR may be asymptomatic
to below the amelocemental junction and the with bacteria. However, Tronstad1 stated that and just detected as a chance radiographic
root covered with attached mucosa to ensure ECR lesions were stimulated and sustained by finding, however, in more advanced cases
alveolar bone maintenance and, in favourable microorganisms in the dentinal tubules and when there is pulpal involvement there may
cases, formation above the decoronated root gingival sulcus and therefore were inflam- be symptoms of (ir)reversible pulpitis and/or
and subsequent ridge preservation until the matory in nature. A molecular study on apical periodontitis.

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 CLINICAL Endodontics

provided by CBCT may change the original

treatment plan and lead to a more effective and
pragmatic management (Fig. 8).23,40–43
Hithersay25 classified ECR into four classes/
stages in order of severity. This classification
aims to assist the clinician in treatment planning.
Class I and II are fibro-vascular in nature and
do not extend below the attachment level and
are easier to treat. Class I lesions manifest as
shallow defects in the dentine but class II defects
penetrate well into the coronal dentine and are
close to the pulp.22 Class III and IV infiltrate the
radicular dentine in complex channels and are
very complicated to treat.2,9,22 Class III defects
invade the coronal third of the root and class
IV lesions extent beyond the coronal third of
the root. However, as this classification is only
two-dimensional, it is only valid if ECR is solely
Fig. 7 External cervical resorption. (a and b) Parallax right bitewing radiographs with ten
confined to the proximal aspects of the tooth. In
degree shift revealing the presence of an irregularly shaped radiolucency at the distal and
cervical aspects of the maxillary right first premolar (green ovals). (c and d) Reconstructed reality, this is not common as external cervical
sagittal CBCT slices confirm the presence of and the true extent and dimension of the ECR resorptive lesions often affect the palatal and
lesion (yellow arrows) buccal aspects of teeth and therefore are under-
estimated. To overcome these limitations, Patel
and co workers proposed a three-dimensional
classification to accurately document the true
nature of ECR (Fig. 9).44
The management of ECR largely depends
on the location, extent, severity, whether the
lesion has perforated the root canal system and
the restorability of the tooth. The management
options of ECR include external repair of the
resorptive defect +/- endodontic treatment,
internal repair and root canal treatment, inten-
tional replantation, periodic review (untreatable
teeth), extraction (untreatable teeth)3,45. The
management of ECR lesions has been described
at length by Patel et al.3 and Hithersay45.

External surface resorption (ESR)

This is a non-infective, transient, pressure-
Fig. 8 External cervical resorption. (a) Periapical radiograph of the maxillary right first induced resorption. This resorptive process
molar. The patient’s chief complaint was tenderness to biting. However, there was no sign of will stop progressing once the source of the
endodontic or periodontal disease. (b) Reconstructed axial, (c) sagittal and (d) coronal CBCT
pressure has been removed, resulting in repair
slices through the same tooth reveal the presence of ECR and the true extent and nature of
of the resorbed root-face with cementum.5,46
the defect (red arrows), which involved the furcation (yellow arrow) and penetrated into the
coronal third of radicular dentine (blue arrow) Orthodontic tooth movement, impacted teeth,
tumours and cysts have been reported to cause
surface resorption.2,5,47
There is no ‘classic’ radiographic appear- that the lesion is ‘external’ to the root canal. Clinical examination is usually
ance; lesion may have well-defined, or This is a pathognomonic sign of ECR. unremarkable.
irregular margins in the cervical aspect of Even with parallax radiographs, early ECR ESR can only be confirmed with radiographs.
the tooth (Fig.  7).3 While early lesions are lesions may not be easily detected. Furthermore, The root apices are blunted and/or the roots
radiolucent due to resorption of hard dental the true extent of these lesions may not be appear shorter in orthodontically treated teeth,
tissue, advanced (fibro-osseous) ECR lesions revealed. It has been well documented that the where perhaps excessive pressure had been
may exhibit a mottled appearance reflecting use of CBCT assists the clinician to determine applied (Fig. 10). Alternatively, the roots may
the attempted repair of the resorbed root the position, depth, and more importantly, the appear saucer-shaped or irregularly-shaped in
structure.3,21 The outline of the root canal will restorability of the affected teeth before the teeth adjacent to an expanding tumour, cyst or
be visible through the lesion thus indicating start of treatment. The additional information impacted tooth.1,2,9,10,48

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 Endodontics CLINICAL

Fig. 9 Three-dimensional classification of ECR. Reproduced from Patel S, Foschi F, Mannocci F, Patel K. External cervical resorption: a
three-dimensional classification. Int Endod J. 2017; 51: 206-214, Wiley

Height Circumferential spread Proximity to the root canal

1: At cemento-enamel junction level or A: ≤90° d: Lesion

coronal to the bone crest (supracrestal)
2: Extends into coronal third of the root B: >90° to ≤180° p: Probable pulpal involvement
and pical to the bone crest (subcrestal)

3: Extends into mid-third of the spot B: >180° to ≤270°

4: Extends into apical of the root D: >270°

CBCT examination can reveal the full

extent and position of the defect and allow
the clinician to assess the true extent of root
destruction (Fig. 11). Typically, a CBCT would
be taken for the management of the tumour,
cyst or impacted teeth rather than specifically
for assessing the nature of the resorptive defect.

Transient apical breakdown (TAB)

Transient apical breakdown (TAB) was first
described by Andreasen & Andreasen49 and is a
non-infected transient resorption of the apical
portion of the root and the adjacent bone. It
has been reported that TAB resolves within
12 months and is associated with moderate
luxation injuries. It has been suggested that
it could be linked to the repair process and
removal of necrotic and injured tissue.5,50
Clinical examination may reveal transient
tooth discolouration and delayed or no
response to sensibility testing. Delayed or no
response to sensibility testing may remain
especially if the tooth undergoes root canal
obliteration (tertiary dentine formation).
Radiographically, there is initial widening
of the periodontal ligament space and blurry
appearance or loss of apical lamina dura may
be observed. The radiographic appearance
of the periodontal ligament and lamina dura
returns to a normal state within a year.
This phenomenon is essentially an external
inflammatory resorption (EIR) with a short
resorption phase followed by repair. It is well
established that even with a beam aiming
device it is not always possible to replicate the
anatomy being assessed, and it is not possible
to obtain exactly the same view with repeat
radiographs taken over a period of time. This
inadvertent geometric distortion resulting in
elongation or foreshortening may contribute to
Fig. 10 External surface resorption. (a, b, c) A series of periapical radiographs revealing
extensive ESR of the maxillary right and left central incisors (green arrows), and to a lesser
extent of the maxillary right lateral incisor. (d and e) The reconstructed sagittal CBCT slices
through the maxillary right (d) and left (e) central incisors reveal the intact lamina dura and
periodontal ligament space in the palatal aspect (yellow arrows)
the appearance of the presence and then disap- though further review and assessment might
pearance of a widened periodontal ligament have demonstrated the transient nature of the
(TAB) over a period of time (Fig. 12).50 signs and symptoms. On the other hand, the
The important clinical consideration for disappearance of the initial radiographic signs
teeth that undergo mild to moderate luxation must not be regarded as the confirmation for
injuries is regular monitoring including TAB diagnosis either, as even a slight change
sensibility testing and radiographic assess- in beam angulation may obscure the presence
ment of the periapical tissues. The preva- of the apical radiolucency and defect.
lence of TAB may have been under-reported
as a result of endodontic treatment being CBCT considerations
commenced. Many asymptomatic teeth with
small widening of the periodontal ligament It is well established that CBCT has an
space, lack of immediate response to sensibil- important role in the diagnosis and manage-
ity testing immediately after mild or moderate ment of complex endodontic problems.41,51–54
luxation injuries or with slight discolouration Only high-resolution small field of view
may have received root canal treatment, even scans can be justified for the diagnosis and

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 CLINICAL Endodontics

CBCT should be seen as an adjunct and not

a replacement for conventional radiography.
A CBCT should only be considered after
thorough clinical and conventional radio-
graphic examination and assessment has been
carried out.
The referrers and interpreters of CBCT
images are strongly advised to follow the
European Society of Endodontology’s position
statement55 on the use of CBCT in endodontics.

Management considerations

The overall decision-making process regarding

the management of resorptive defects must
be based on the nature and cause of the
resorption, the prognosis and restorability.
Furthermore, to obtain informed consent, the
Fig. 11 External surface resorption. (a) Periapical radiograph of the maxillary right incisor benefits and risks of any intervention must be
tooth immediately following extrusive luxation. (b) The nonvital and traumatised teeth were fully discussed with the patient.7,58 The man-
repositioned and subsequently endodontically treated. (c and d) 4-year review radiographs
agement must focus on the removal of the
reveal signs of ESR on the mesial and distal aspects of the maxillary right incisor (yellow
source of resorption and its repair.7,58
arrows). (e) The axial and (f) coronal CBCT slices confirm surface resorption and the presence
of intact lamina dura (red arrows) Unrestorable (symptomatic) teeth may be
extracted in medically fit and healthy patients.
In restorable teeth with signs and symptoms
of irreversible pulpitis or apical periodontitis,
root canal treatment should be carried out.
Ideally, the resorptive lesion should be assessed
using a small FOV CBCT as described previ-
ously to assess its nature and rule out perfora-
tions/root canal communications and risk of
causing hypochlorite accidents.7,58
If the uninfected defect is inaccessible or
requires extensive alveolar bone and tooth
structure removal to be repaired, a decision
may be made to leave and monitor the lesion
as the lesion may cease to progress and move
into repair stage.
The management of resorptive defects have
been comprehensively addressed by Patel et al.
(2016)7 and Darcey and Qualtrough (2013).58
Fig. 12 Transient apical breakdown? (a) A periapical radiograph revealing widening of the
periodontal ligament space and loss of apical lamina dura associated with the maxillary left
central incisor following subluxation injury to the maxillary anterior teeth (yellow arrow). The
Conclusion
PDL and lamina dura on the maxillary right central incisor appear intact (b) 6-months follow-up
The aim of this paper was to provide a
radiograph demonstrates the resolution of TAB on the maxillary left central incisor (green
arrow). However, the maxillary right central incisor is associated with a loss of apical lamina practical guide to diagnosis and treatment of
dura. (c, d, e) Coronal and sagittal CBCT slices of the same teeth reveal well defined periapical dental resorption lesions using a systematic
radiolucencies associated with the maxillary right and left central incisors (red arrows). The classification.
diagnosis of chronic periapical periodontitis associated with infected necrotic pulp was reached Accurate diagnosis is required for sound
clinical decision making, treatment planning
management of resorptive lesions. It is essential The risks and benefits of a CBCT scan and execution of the treatment. A CBCT may
to optimise the radiation dose, thus minimise must be fully discussed with patients and be indicated to confirm the diagnosis and/
patient exposure to radiation.55 This will ensure an informed consent obtained before any or aid management. When appropriate, the
compliance with the ALARA ‘as low as rea- exposure. In addition, clinicians should clinician may wish to consider referring the
sonably achievable’ principle and achieve the undergo appropriate training to gain patient for a specialist opinion.
lowest effective dose based on the number of knowledge of CBCT radiography before pre- Patients must be fully informed of the
teeth affected and sites involved. scribing CBCT scans.56,57 treatment options, the prognosis of the lesions

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and the success of the treatment. Treatment
planning must be realistic and take into
account the type and stage of the resorptive
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