Aust Endod J 2020

CASE REPORT

Management of a perforating internal root resorption using

mineral trioxide aggregate: a case report with 5-year follow-up

rgio Andre
Rui Pereira da Costa1,2; Se
Quaresma1,2; Fabiane Carneiro Lopes1; Rafael Camargo1; Mariana
2
Domingos Pires ; Anto
nio Ginjeira ; and Manoel Damia
2
~o Sousa-Neto1
1 Department of Restorative Dentistry, School of Dentistry of Ribeir~ao Preto, University of S~
ao Paulo, S~ao Paulo, Brazil
2 Department of Endodontics, School of Dentistry of Lisbon, Universidade de Lisboa, Lisboa, Portugal

Keywords
case reports, clinical follow-up, endodontic
treatment, internal resorption, mineral trioxide
aggregate.
Correspondence
Manoel D. Sousa Neto, Rua Ce
lia de Oliveira
Meirelles 350, 14024-070 Ribeir~ao Preto, SP,
Brasil. Email: sousanet@forp.usp.br
doi: 10.1111/aej.12436
(Accepted for publication 8 August 2020.)
Abstract
Internal root resorption is characterised by progressive loss of tooth substance
initiating at the root canal wall as a result of clastic activity. This report
describes a case of a perforating internal root resorption on a maxillary central
incisor in a 25-year-old patient. The perforating internal root resorption was
firstly diagnosed with periapical radiographs and assessed with full detail with
the aid of CBCT, allowing determination of the extension and areas involved
in the resorption lesion, as well as the treatment planning. According to these
findings, a MTA barrier was performed on the root, -coronally to the resorp-
tion lesion, leaving the root apically to the resorption lesion untouched. Clini-
cal findings and periapical radiographs indicated complete resolution of the
radiolucency associated with the resorptive defect, with reestablishment of
lamina dura along the root and occlusion of the lumen of the root canal in the
apical segment, after a 5-year follow-up.

tooth may at least be partially vital and may indicate

Introduction
Internal root resorption is defined as the progressive
destruction of internal radicular dentin throughout the
middle and apical thirds of the canal walls as a result of
odontoclastic activity. It is a pathologic process that
involves, first, a disruption of the outermost protective
odontoblast layer and predentin (1). The inflammatory
process is only perpetuated while there is a bacteriologi-
cal stimulus within the canal, namely necrotic pulp tissue
coronally to the defect, and vital pulp tissue apically (2).
The exact causes of internal resorption are still unknown.
Nevertheless, it has been proposed that trauma, pulpitis,
pulpotomy, a cracked tooth, tooth transplantation,
restorative procedures, invagination, orthodontic treat-
ment and even herpes zoster viral infection are all possi-
ble and likely predisposing factors (3). Although several
aetiological factors have been considered for the loss of
predentin, trauma has been the most advocated (4), as
odontoclastic activity is mainly related with chronic pulp
inflammation and trauma (1). Internal root resorption is
normally asymptomatic and often recognised clinically
through routine radiographic investigations. However,
when the resorption is predominantly expanding, the
signs typical of pulpitis. Internal root resorption is a rela-
tively rare occurrence, and the first report of internal root
resorption dates to 1830 (5).
The suggested prevalence for this pathology between
0.01% and 1% (patients affected), but might have be
an underestimation, based on few clinical reports (6).
The condition might go unnoticed until the lesion has
advanced significantly and is usually detected in rou-
tine radiographs. Incorrect diagnosis might result in
inappropriate treatment in certain cases and, if
untreated, might result in the premature loss of the
affected teeth (1).
Several possible treatments of perforating internal root
resorption have been reported, including long-term cal-
cium hydroxide treatment (6), repair with mineral triox-
ide aggregate (7), surgical treatment (8), combined non-
surgical and surgical treatment (3), regenerative
endodontic treatment (9) and concomitant periodontal
surgery and mineral trioxide aggregate repair (10).
In this clinical case we describe the non-surgical
endodontic management of a perforating internal resorp-
tion of a permanent central incisor with the use of min-
eral trioxide aggregate.

© 2020 Australian Society of Endodontology Inc 1

Management of Perforating Internal Root Resorption R. Pereira da Costa et al.

Buccal infiltration anaesthesia was performed using

Case report
A 25-year-old Caucasian female presented to an appoint-
ment for a check-up of the oral health condition. The
medical history was non-contributory. The patient had
undergone orthodontic treatment several years ago, and
the upper and lower incisors had a fixed ferrule metallic
splint over the palatal and lingual surfaces. Radiographic
and tomographic examination revealed a large radiolu-
cent lesion mid-root of tooth 11 (maxillary right central
incisor), with loss of continuity of the root distally
(Fig. 1a to f and Fig. 2a). No periodontal pockets were
present, and the tooth mobility was within physiological
limits. Tooth 11 was tender to percussion but not on pal-
pation, contrary to tooth 21, which responded asymp-
tomatically in both. There was no response to the cold
sensitive test (Endo cold spray, Henry Schein, Germany)
on tooth 11 and a normal response was elicited on tooth
21. A clinical diagnosis of necrotic pulp with asymp-
tomatic apical periodontitis on tooth 11 was made, along
with a radiographic diagnosis of perforating internal root
resorption. The clinical condition was explained to the
patient. Non-surgical endodontic therapy was proposed
and accepted.
1.8 mL of 4% articaine with 1:200 000 epinephrine
(Artinibsa, Inibsa, Spain) and isolation with rubber dam
was obtained prior to establishing endodontic access.
Determination of working length was performed with an
electronic apex locator (Root Zx II, Morita, USA) and
confirmed radiographically. Minimal instrumentation
was done with manual stainless-steel K-files, with gentle
brushing of the canal walls to disrupt the biofilm and
remove infected dentine, leaving the root apically to the
resorption defect, untouched. After continuous intra-
canal irrigation with 5.25% sodium hypochlorite, a final
irrigation protocol included a one-minute irrigation rinse
with 17% EDTA, prior to a final 5.25% sodium
hypochlorite rinse under ultrasonic agitation. Before
obturation, a rinse with alcohol was done and the canal,
coronal to the resorption defect, was dried with paper
points. Obturation of the canal upper to the resorptive
lesion was made with MTA (ProRoot MTA, Dentsply
Tulsa Dental, USA), a wet cotton pellet was placed over
the material and the tooth provisionally restored with
Cavit (Cavit W, 3M ESPE, Germany). On a second
appointment, one week later, setting of MTA was con-
firmed with manual condensers, and the root was sealed

(a) (b) (c)

(d) (e) (f )

Figure 1 Corono-apical sequence of axial views of cone beam computerised tomography, showing complete integrity on the coronal third of the root
of tooth 11. a) The beginning of the resorption defect is perceptible at the transition between coronal and middle third of the root of tooth 11. b) At
mid-root level, a massive reabsorbed area is very evident at mid-root level of tooth 11. c) Only a small region of the root at mesial level is preserved,
preventing full separation in two root fragments. d) Apically to this area, the root regains its integrity, still showing a radiolucency on the distal surface
of the root. e) Finally reaching apically a point where the root has again complete integrity.

2 © 2020 Australian Society of Endodontology Inc

R. Pereira da Costa et al.
(a) (b) (c)
(d) (e) (f)
Figure 2 a) Pre-operative periapical radiograph showing internal
resorption of upper left permanent incisor (tooth 21). b) Immediate post-
operative periapical radiograph with MTA obturation up to the resorp-
tive defect and resin composite definitive restoration of the endodontic
access. c) Six-month post-operative periapical radiograph showing
almost complete resolution of radiolucent lesion associated with the
resorptive margin. d) One-year post-operative periapical radiograph
showing almost complete resolution of radiolucent lesion associated
with the resorptive margin. e) Two-year and six-month post-operative
periapical radiograph showing complete resolution of radiolucent lesion
associated with the resorptive margin, with deposition of mineralised
tissue and occlusion of the lumen of the root canal of the apical seg-
ment. f) Five-year and nine-month post-operative periapical radiograph
showing complete resolution of radiolucent lesion associated with the
resorptive margin, with deposition of mineralised tissue and occlusion
of the lumen of the root canal of the apical segment.
coronally with flowable composite resin. A definitive
restoration with composite resin was made over the
access cavity (Fig. 2b).
The patient was scheduled for follow-up at 6 months,
at which time a periapical radiograph showed a decrease
of the lateral radiolucency (Fig. 2c). The same tendency
was observed at the one-year and two-year follow-up
appointments. Formation of a mineralised tissue over the
defect could also be noticed. Continued deposition of
mineralised tissue was observed radiographically at one
year (Fig. 2d) and two-year and six-month follow-up
appointments (Fig. 2e). At five-year and 9-month post-
treatment, there was complete resolution of the radiolu-
cency associated with the resorptive defect, with reestab-
lishment of lamina dura along the root and occlusion of
the lumen of the root canal in the apical segment, with
no sign nor symptoms of apical periodontitis (Fig. 2f).
© 2020 Australian Society of Endodontology Inc
Management of Perforating Internal Root Resorption
Discussion
Internal root resorption is dependent on two necessary
and concomitant pre-conditions: vitality of the pulp tis-
sue apical to the resorption, and partial or complete
necrosis of the pulp tissue coronally (2). The blood supply
of the apical vital pulp provides the source for clastic cells
and nutrients, while the necrotic tissue serves as the
stimulant of the resorptive events mediated by the clastic
cells. Without this stimulus, the resorption process is self-
limited (6).
If left untreated, necrosis progresses through the entire
canal and eventually leads to the development of apical
periodontitis. In most cases, including the one reported,
teeth are asymptomatic, and the defect is detected on rou-
tine radiographs. The resorption is usually seen as a radi-
olucent, round and symmetrical widening of the root canal
space, with loss of continuity of the root canal at the
resorption area. However, differential diagnosis with exter-
nal cervical resorption must be made as this might have
implication in treatment planning and prognosis of the
affected tooth (1). Conventional radiographic images allow
a two-dimensional evaluation of a three-dimensional
structure, which may be prone to interpretation errors. For
that reason, 3D evaluation of the resorption area with cone
beam computerised tomography (CBCT) ensures crucial
knowledge for early disease recognition and treatment
methods. CBCT provides detailed and precise information
on the extent, form and nature of the lesion including root
perforations (11), thus allowing a proper planning (12).
The internal resorption diagnosis is based mainly on
radiographic and tomographic criteria supplemented by
clinical findings from history and examination (6,13).
Figure 3 shows a diagram simulating the evolution of a
internal resorption. In this reported case, the resorption
had an advanced state at the time of diagnosis (Fig. 1c
and Fig. 2a), similar to the phase illustrated in Figure 3d.
Cone beam computerised tomography allowed the 3D
assessment of the exact location and extension of the
resorptive lesion, highlighting the impairment and com-
plete destruction of the buccal, distal and palatal root sur-
faces, at middle-root level, with smooth and clearly
defined margins and uniform radiolucency density
(Fig. 1c). It also revealed the absence of apical periodon-
titis lesion, with bone loss restricted to the area immedi-
ately adjacent to the resorptive defect. That was
considered as an indication of the maintained vitality of
the pulp tissue located apically to the resorptive lesion.
Endodontic management was done considering two par-
tially separated fragments with different endodontic diag-
nosis and aiming at maintaining the vitality of the apical
pulp tissue.
3
Management of Perforating Internal Root Resorption
Chemo-mechanical debridement of teeth with resorp-
tive defects might pose challenges related with the diffi-
culties in eliminating necrotic tissues within the root
canal. When the resorption extends to a point where
there is perforation of the root structure, extra care must
be taken to preserve as much remaining tooth structure
as possible, attempting not to weaken it even further,
and leave it at increased risk of fracture. Mechanical
debridement in the reported case was limited to careful
disruption of the canal content with manual stainless-
steel K-files, to lessen damage to the remaining dentin.
Irrigation was done with 5.25 % sodium hypochlorite
and the final irrigation protocol included a chelating
agent – 17% EDTA – as an adjuvant to chemical disinfec-
tion (14,15). Furthermore, ultrasonic activation of the
sodium hypochlorite was included as a means of increas-
ing penetration of the irrigant to all areas of the root
canal system and break loose necrotic tissue in the canal.
Even though the literature lack good quality evidence-
based material to support the inclusion of ultrasonic acti-
vation in endodontic treatment protocols in general, a
recent systematic review stipulates that ultrasonic activa-
tion of irrigants is more effective in the removal of pulp
tissue remnants based on both clinical and in vitro stud-
ies, and also more effective in the removal of hard tissue
debris in vitro (16).
In the presence of a perforating internal root resorp-
tion, mineral trioxide aggregate (MTA) is a perforation
repair material with favourable results (17). In situations
where the root wall has been perforated, mineral trioxide
aggregate should be considered the material of choice
Figure 3 Diagram simulating the evolution of the internal resorption. a)
3D model of tooth 11 (maxillary right central incisor). b) 3D model of
tooth 11 with a early stage of internal resorption located at mid-root
level. c) 3D model of tooth 11 with internal resorption located at mid-
root level in an intermediate stage of evolution, without communication
with periapical tissue. d) 3D model of tooth 11 with internal resorption in
a advanced stage located at mid-root level, with lateral rupture on the
distal level, and only a small region of the root preserved at mesial level,
preventing full separation in two root fragments, similar to the stage of
the case reported (Fig. 1c).
4 © 2020 Australian Society of Endodontology Inc
R. Pereira da Costa et al.
due to its excellent sealing ability and biocompatibility
(18,19), bactericidal effects, and radiopacity (20), as well
as the capacity to regenerate periodontal attachment and
induce both osteogenesis and cementogenesis (17). The
presence of pathological changes in the periodontal tis-
sues close to an advanced perforating resorption increases
the risk of overfilling. In the presented case, as in other
published case reports, it was extremely difficult to avoid
material extravasations into the periradicular lesion (7).
Nevertheless, inadvertent extrusion should not pose a
problem as the material provides a highly biocompatible
interface with the periradicular tissues (21).
Reinforcement of the coronal structure was done with
intracoronal restoration of the access with a resin com-
posite.
Even though current evidence supports short-term,
non-rigid splints for splinting of root-fractured teeth
(22), and even though this case can almost be included
in this group due to the massive root tissue loss as a result
of the resorption process, as the patient had already
arrived with an installed metallic splint for orthodontic
reasons, it was decided to keep the splint in place, also
for root stabilisation in the first stages after treatment,
but mainly for orthodontic reasons. While orthodontic
relapse does not happen in every patient, clinically it is
difficult to predict which patients will undergo post-treat-
ment change. As a result, many clinicians now recom-
mend life-long retention. Fixed retention may be
preferred following closure of a spaced dentition (includ-
ing a marked median diastema), following correction of
severe rotations, for patients who cannot tolerate even
minor changes in occlusion, following correction of
severely impacted teeth, or in compromised cases in
which the aims of treatment may be more limited, and
focus is geared more towards achieving a good aesthetic
result without aiming for a fully corrected malocclusion
with ideal occlusion (23).
Although there is a lack of follow-up studies on the
long-term prognosis of treatment of teeth with internal
root resorption, clinical experience and case reports allow
the assumption of good prognosis especially when there
is no extension up to a perforation defect. In this case,
the five-year follow-up showed that the treatment
options were successful, with complete resolution of the
lesion associated with the resorption site, without any
signs or symptoms of pathology. Moreover, radiographic
controls at six months, one year, two years and six
months, and finally five years and nine months showed
deposition of a mineralised tissue and reconstitution of
the root anatomy. This type of repair has been reported
in the literature on root fractures and is speculated to be
related more with the maintenance of a healthy peri-
odontal ligament than with the vital pulp tissue (22,24).
R. Pereira da Costa et al.
On the other hand, there was also a progressive narrow-
ing of the canal lumen in the apical segment.
Conclusion
Even though internal perforating resorptions can be a
clinical challenge, this case report highlights the impor-
tance of the use of cone beam computerised tomography
as a diagnostic and treatment planning tool, as well as the
importance of use of bioactive materials as a means of
promoting mineralised tissue deposition and healing, thus
allowing a more conservative approach for the clinician.
Acknowledgements
‘The authors deny any conflicts of interest. We affirm
that we have no financial affiliation (e.g. employment,
direct payment, stock holdings, retainers, consul-
tantships, patent licensing arrangements or honoraria),
or involvement with any commercial organisation with
direct financial interest in the subject or materials dis-
cussed in this manuscript, nor have any such arrange-
ments existed in the past three years’.
Author Contributions and Declaration
RPC conducted the clinical case. MDSN and AG per-
formed formal analysis and supervision. MDSN, FCL and
RPC project administration. RPC, SAQ and MP conducted
resources. RPC, SAQ, FCL, RC, MP and AG e MDSN con-
tributed to conception and organisation of the manu-
script. RPC, SAQ, FCL, RC, MP and AG e MDSN have
read, reviewed and approved the final manuscript. All
authors have contributed significantly and are in agree-
ment with the manuscript.
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6 © 2020 Australian Society of Endodontology Inc