Lec 6 Endo

Root Resorption

Chapter Outline
1-Definition 2-Mechanism of tooth resorption 3-Classification of root resorption
4-Internal resorption 5-External resorption 6-Guided tissue Regeneration (GTR)
7-HELPFUL TIPS (4 TIPS)

NOTE : and we will talk Separately about :

A- Etiology of internal Root Resorption (6 causes)
B- Etiology of External Root Resorption (8 causes)

1-Definition of root resorption

Def.: Root resorption is a physiologic or a pathologic process, which results in → loss of the
cementum , dentin OR Both (Dentin & Cementum) of the root of a tooth.
NOTE: Physiologic Root resorption (occurs
with normal eruption as permanent tooth
resorbs the Deciduous tooth root
during eruption )

Clast cells

Clast cells are: (Odontoclast , Osteoclast , Cemntoclast)

Origin of Clast cell : when Injury occurs → inflammation & increase blood supply occurs , then Blood
monocyte will form macrophages …. These macrophages → join & fuse together to form Giant cells ,
resulting in formation of (Clast cells)
NOTE: so, Clast cells are a result of (union OR fusion)
of macrophages together
 2-Mechanism of tooth resorption
1- 1st (Degradation of inorganic material = Degradation of Hydroxyapatite )
2- 2nd (Degradation of organic material = collagen , proteins , polysaccharide , trace elements )
NOTE: so, Mechanism of tooth resorption starts with Degradation of inorganic material then
Degradation of organic material
NOTE: Clastic cells are attracted to mineralized tissues by their ruffled borders.
NOTE: Clastic cells are NOT attracted to Less mineralized tissues
NOTE: when Clastic cells are attracted to mineralized tissues by their ruffled
borders , it release enzymes that creates (Acidic media) which starts the
Resorption & formation of Lacuna –‫متشاور عليها بالسهم االصفر‬- as a Result of
(Degradation of inorganic material then Degradation of organic material)
NOTE: The lacuna allow more & more penetration of Clastic
cells and this will result in → (more & more degradations)

NOTE: The Clast cells comes from the blood & reach the
Tooth via the → Tissue that are in contact with blood (Which
are PDL & Pulp)

NOTE: Cementum (is covered with cemntiod tissue )

NOTE: cemntiod tissue is = less mineralized , so Clastic cells are NOT attracted to it (‫)و دا ديفينس مكانيزم‬
NOTE: Dentin (is covered with Predentin tissue )
NOTE: Predentin is = less mineralized , so Clastic cells are NOT attracted to it (‫)و دا ديفينس مكانيزم‬
NOTE: Anti-Resorptive factors are (cemntiod tissue & Predentin tissue) are considered as Defense
mechanisms (as the Clastic cells are NOT attracted to Less mineralized tissues)
NOTE: if (cemntiod tissue & Predentin tissue) are removed & degraded → Resorption occurs

3-Classification of root resorption

Classification of root resorption ( Acc. to the site of Origin ) :
1-Internal Root Resorption: (A- Transient , B-Progressive , C- Replacement ) IRR → Comes from (PULP)
ERR → Comes from (PDL)
2-External Root Resorption: (A- Acc. To injury , B- Acc. To location)

2-Classification of External Root Resorption (A- Acc. To injury) :

1- Surface
2- Replacement (Ankylosis)
3- Inflammatory
2-Classification of External Root Resorption (B- Acc. To location) :
3- Cervical –‫اخطر واحد‬- it could be → (A-Supraosseous , B-Intraosseous , C- Crestal )
2- Lateral
3- Apical
 4-Internal Root resorption
NOTE: The protective layer (Predentin tissue) is Destructed and resulted in (Internal Root Resorption)
We will talk about :
(A-Etiology , B-Diagnosis , C-Treatment of internal Resorption without perforation & its Difficulties ,
D-Treatment with perforation , E-Surgical Treatment of internal Resorption )

A- Etiology of internal Root Resorption (6 causes)

The damage of the Protective Predentin layer may be caused by:
1-Trauma
2-Pulpal Metaplasia due to → (Toxic materials, diathermy).
3-Inflammation/Infection e.g.: (caries , Periodontal Infection, excessive heat generation).
4-Endocrine Dysfunction.
5-Viral infection as → Herpes Zoster.
6-Idiopathic Changes.

NOTE: If trauma occurred , it will result in :

1-Intra pulpal hemorrhage
2-Then Granulation tissue forms and it compress the dentin walls
3- Then stimulation of odontoclasts occurs , and it will start (Dentin Resorption)
4-The Pink spot tooth is the End result of The IRR
NOTE: (Pink tooth = the reflection of enamel the underling Granulation tissue)
NOTE: The Pulp polyp also has this same Concept

B-Diagnosis of Internal Root Resorption

1-At IRR Pulp is → Vital and Asymptomatic + (Pt. may notice Pink discoloration )
2-if perforation of pulp occurs & pulp became in contact with oral cavity , it will be → Necrotic and
Symptomatic
3-Periapical Radiograph in IRR (smooth clearly defined margins = ballooning out ) of pulp space
3-The Radiolucency in IRR is → uniform in density
4- in IRR Lesion is within the confine of the root of root canal on R.G
NOTE: IRR is discovered Accidentally during (Routine X-ray examination)
The pink spot

C-Treatment of Internal Root Resorption

Treatment of Internal Root Resorption could be :
1- non surgical (A-without Perforation) OR (B-with perforation)
2- Surgical
NOTE: TTT Should be carried out as soon as the resorptive process
has been diagnosed (as the Clast cells will not stop the destruction of the
protective layers ) – ‫كل ما اسرعت فالتريتمنت كل ما بقى احسن‬- .
 Treatment of Internal Root Resorption (A-without Perforation)
NOTE: obtained TTT in case of Internal Root Resorption (without Perforation) is → (RCT)

Certain difficulties are associated with RCT of Internal resorption (without perforation)
A-hemorrhage (after accesses prep.)
B-pulp tissue in inaccessible areas (During mechanical prep.)
C-Filling technique (During obturation )
NOTE: the key of successes in RCT is → to remove all the inflamed tissue , if
any Remnants of pulp tissue Remained after obturation → the Clast cells
will not stop the resorption process

A- Management of hemorrhage in Internal resorption (without perforation)

1-Do Total pulp extirpation
2-use NaOCl 5.25% irrigant → (as it stops bleeding & Remove inorganic tissue )
3- use homeostatic agent OR V.C (with Total pulp extirpation & NaOCl 5.25% )
if the bleeding didn’t stop

B- Management of pulp tissue in inaccessible areas in Internal resorption (without perforation)

NOTE: After hemorrhage has been stopped , Do the following in mechanical prep. :
1- Ultrasonic activation of irrigants → as it has 2 main advantages :
1- produces Acoustic streaming (thus irrigants will reach the lateral canal)
2- produces Bubbles (that hits the wall of Dentin & remove the tissues)

2- Use of ICM as Ca(OH)2 OR Ledermix OR Double/Triple Antibiotic paste : (to ensure complete
removal of tissue )
NOTE: (Antibiotic inflammatory paste , calcitonin hormone , CPE = Cemntum protien extracts) are ICMs

C- Management of Filling technique in Internal resorption (without perforation)

1-Size of canal ( ‫)شبه ساعة االيد زي ماهو باين فالديجارام تحت‬
2-irregularity of canal (this will prevent the Lateral compaction tech.
so, we will use Obtura-sytem with Flowable G.P instead )
3-inacssesability of canal

Filling technique:
We will use (Thermo-plasticized injectable warm GP → Due to
the irregular shape of the root canal) , so at 1st obturate the apical
part filled by the Master cone
then rest of the canal filled with Flowable Gutta percha (apply
layer by layer By obtura-system & do condensation for each layer ).
 Treatment of Internal Root Resorption (B-with Perforation)
NOTE: obtained TTT in case of Internal Root Resorption (with Perforation) is → (Re-calcification) BUT
this is only done in (small-medium perforation)
NOTE: if the perforation is large in sized in Internal Root Resorption, the obtained TTT in case of is →
(Surgical Treatment)

NOTE: Re-Calcification of (small-medium perforation) can be done by Either Ca(OH)2 OR MTA

1-Ca(OH)2 (it is used → Due to its high alkalinity to neutralize the acidic media of resorption )
NOTE: Ca(OH)2 has the following properties :
A- Antimicrobial.
B- Reduction of the inflammatory response
C- Stimulation of the dentinoblast (that aids in formation of calcific barrier ).
D- Inhibition of the dentino-clastic activity
E- High Solubility ( so, it must be changed every 3 months to refresh Ca(OH)2 till formation of C.Barrier)
F- calcific barrier (takes about 6-20 months to form)
G -After deposition of a calcific barrier → obturation with thermo-plasticized GP

2- MTA repair perforation

NOTE: at this technique , we do flap → then (PUT the Master cone OR MAF
OR Paper point inside the canal to avoid any blockage during application
of MTA) → then apply MTA to repair the perforation → then do obturation
NOTE: MTA has the following properties :
A-It is a biocompatible material.
B-Setting in moisture environment and high Ph value
C-Good sealing ability.

Surgical Treatment of Internal Root Resorption

Indications of Surgical Treatment of Internal Root Resorption:
1- In difficult cases when non-surgical approach can’t seal the defect OR control bleeding.
2- Altered anatomy of root apex by resorptive defect.
3- Perforation near OR at the epithelial attachment.
4- Unsuccessful calcification.
 5-External Root resorption

NOTE: The protective layer (Cemntiod tissue) is Destructed and resulted in (External Root Resorption)
1- In cases of trauma, necrotic PDL tissue remnants are excavated and removed by macrophages and
osteoclasts.
2-A critical factor is that the precementum may be (stripped from the root surface) & hence , the
Cementum is exposed → then Clast cells will attach to the cementum → this will result in damaging
& phagocytosis of cementum and bone → and as a sequel , exposure of the underling dentin will
occur due to osteoclastic and odontoelastic activity.

A- Etiology of External Root Resorption (8 causes)

1-Inflammation/ Infection 2- Orthodontic treatment 3-Pathological (Tumors and Cysts)
4-Impaction 5- Replantation after traumatic avulsion of teeth in 80-96%.
6- Chemical Trauma 7- Systemic diseases disrupting the calcium metabolism
8-Idiopathic as in case of → Hemi-facial atrophy (Parry-Romberg syndrome)

1-Inflammation/ Infection from :

1-An inflamed OR necrotic pulp → stimulating phagocytosis and osteoclastic activity (through D.T)
2-Low pH value & presence of microbes (that reached via D.T) will lead to → bone & root resorption.
(PIC A) shows → Preoperative Radiographic picture of a molar with (external apical resorption) due
to apical infection.
(PIC B) shows → 6 month follow up after root canal therapy.

2- Orthodontic treatment :
Orthodontic TTT exerts (excessive force) leading to → necrosis of the
periodontium and release of inflammatory mediators leading to
root resorption and loosening of teeth –‫والسنة هتقع فاالخر‬-
 A- Etiology of External Root Resorption (8 causes) cont.
3-Pathological (Tumors and Cysts) exert pressure & local factors leading to → bone & tooth resorption
4-Impaction compresses on the surrounding tissues stimulating resorption (‫)تالقي السفن بايظ بسبب الويزدوم‬.

5- Replantation after traumatic avulsion of teeth in 80-96%.

NOTE: if the pt. didn’t handle the tooth from the Crown
OR didn’t store it in a storage media → External RR will
occur

NOTE: The more the intensity of trauma to the PDL→ the

less healing outcome
NOTE: Order of likelihood (from favorable to
unfavorable healing outcomes ) , following the
different categories of luxation injuries.
NOTE: the (intrusion) has the lowest healing outcome ,
followed by (Avulsion) .. and Both of them (are
the most associated with External Root resorption )
NOTE: (Lateral luxation) , (Extrusive luxation) , (Subluxation) and (concussion) → have low
association with External Root resorption –‫ولو حصل اكسترنال رووت ريسزوبشن بيبقى قليل اووووي ونسبته قليلة‬-

6-Idiopathic as in case of → Hemi-facial atrophy

(Parry-Romberg syndrome)
NOTE: there is atrophy in (Muscles & Bone) and
there is (impairment in Calcium level)
 A- Etiology of External Root Resorption (8 causes) cont..
7- Systemic diseases disrupting the calcium metabolism as :
(A- hyperparathyroidism , B- Goucher’s disease , C- Turner syndrome , D- Calcinosis , E-Herpes zoster )
NOTE: all these systemic disease will result in
(External root resorption)

8- Chemical Trauma: (Acids and bleaching agents) may leak from the pulp to the periodontal
ligament when performing internal bleaching for the tooth through the dentinal tubules, causing →
External Cervical Root Resorption
NOTE: the internal bleaching material (Has high amount of O2) and when it passes the D.T → it will
result in (stimulation of macrophages & Clast cells)

NOTE (‫)مهم جدا‬: Cervical Root resorption is the

most common type of ERR that occur due to
using (Internal bleaching material)

NOTE (‫)مهم جدا‬: Cervical Root resorption is The

most danger type of ERR (it is very serious
in TTT & it is very serious to protect )
Heithersay’s classification of (invasive cervical root resorption)
Class I Small invasive resorptive lesion (Near cervical area) with shallow penetration into
dentin
Class II Well defined invasive resorptive lesion that has (penetrated close to the coronal pulp)
BUT with little or no extension into the radicular dentin
Class III Deeper invasion of root Dentin By Resorbing tissue that extend into the coronal 3rd of
the root
Class IV Large invasive resorptive process that extend (beyond the coronal 3rd of the root)

Clinical Diagnosis of invasive cervical root resorption

1-Pink Spot
2-catching By probe (at cervical part of tooth)
3-Granulation tissue
4-Spontaneous bleeding

(REMEBER) Pink spot tooth is associated with

1- internal Root Resorption 2- invasive External cervical root resorption
 To prevent External Cervical Resorption induced by Internal bleaching
(It should be Noted that)
1- Protect the DT by placing a layer of cement over the GP (to prevent leaching of bleaching
materials through the DT).
2- Eliminate the use of (heat of thermocatalytic procedure).
3- Avoid etching Dentin → as it opens DT and Lead a direct path to the gingival tissue.
4- Beware of → the caustic nature of superoxol (as it has High amount of H2O2 & used in int. bleach )

NOTE (Remember): Classification of External Root Resorption (A- Acc. To injury) :

1- Surface 2- Replacement( Ankylosis) 3- Inflammatory

Classification of External Root Resorption (Acc. To injury)

Type 1- Surface 2- Replacement ( Ankylosis) 3- Inflammatory

Small inflammation 1-Continuous bone remodeling 1-it is the MOST Aggressive
Characterized without microorganism (lead to fusing/ankylosis of bone 2-there is Microbial infl.
with with the root ) 3- there is Infected necrotic
2-No vital PDL pulp

Etiology Trauma with low Trauma with irreversible damage to
intensity PDL
Clinically No sign of resorption Metallic sound (on percussion)
R.G 1-Normal LD. 1-Loss of LD
2-Small excavation 2-RO union between tooth and
Treatment No TTT (as it is Self- In case of ankylosed (Mature
heal) tooth):
1-normal occlusion; leave and
NOTE: (only do follow monitor (for ultimate implant TTT)
up to check if there is 2-infra-occlusion: surgical reposition
no progression ) , stabilization + Emdogain
In case of ankylosed (Immature
tooth) :
infra-occlusion; surgically reposition
& treat root surface with Emdogain
OR (decoronate and submerge).
NOTE : Emdogain is (a membrane )
applied on root surface to allow
normal heal of tooth
1-Avulsed tooth
2-Luxation injury
3-Orthodontic TTT
1-All necrotic sign
2-Discolored tooth
3-No response vitality test
1-Loss of LD.
2-Concaved ,ragged ,bowel
shaped RL
1- Endo-TTT & ICM with either
(Ledermix paste) followed by
(Long term of CaOH2) to stop
the inflammatory process
2-Root fill when resorption
controlled
NOTE: Ledermix (TobraDex) is
a mix of corticosteroid &
antibiotic
NOTE: if TTT is not obtained
during 2-3 days → tooth will
be destructed
(‫)هتكون السنة خلصت‬
 Treatment of External Resorption
1- Surface Resorption :
A-Monitor radiographically.
B- Endodontic TTT is done (only if signs of infection).
2- Pressure: Remove cause (e.g. un-erupted cuspid, neoplasm) to decrease the Resorption .
3- Orthodontic : Should stabilize on completion of orthodontic treatment

NOTE: Prevention of External Resorption (following replantation of mature tooth , pulp

extirpation and Ledermix paste dressing as soon as possible)

Intracanal Medications used in Inflammatory root Resorption

1- Ledermix → (Antibiotic/corticosteroid) paste.
2- Calcitonin → (Hormone that inhibit osteoclastic bone resorption activity ) .
3- Osteoprotegrin and Bisphosphonates (they inhibit osteoclastic activity )

Communicating internal-external inflammatory resorption (EXTRA)

1- Endodontic treatment to resorptive defect.
2- Induce calcification by (use calcium hydroxide alone) OR (following careful topical application
of 90% trichloraceti acid.)
NOTE: ProRoot MTA may also be used.
3- Guided tissue Regeneration (GTR) → allow better results than conventional surgical techniques
as it allows regeneration of PL cells to populate the surface of the tooth preventing healing with
epithelial cells.
 NOTE (Remember): Classification of External Root Resorption ( Acc. To location) :
1- Apical 2- Lateral
3- Cervical –‫اخطر واحد‬- it could be → (A-Supraosseous , B-Intraosseous , C- Crestal )

1-Treatment of External apical root resorption

NOTE : TTT will depend on the situation of the apex
A-(if there is small affection in apical constriction) : Do obturation using
(Inverted cone/ tailor made technique of GP)
B-( if there is Large affection at apex & the Apex is not closed) :
1- go for MTA plug then →obturation
2- OR Apexification (using CaOH2 & follow up every 3 months till calcific barrier forms) then →obturation
N.B : 6-12 months showed persistence of apical pathosis → surgical approach is done

2-Treatment of External Lateral root resorption

A- Non perforating : use Ca(oH)2 for→ Re-calcification technique (as it go within D.T)
B- perforating:
1-first with Ca(OH)2 and followed up with X-Rays & follow up every 3 months
till calcific barrier forms (for maximum 24-30 month)
2-if NO improvement –within 20 months- then (surgical intervention & filling
the resorption with amalgam ,IRM, Cavit, Composite resin, or G.ionomer )

3-Treatment of External Cervical root resorption (THE PINK TOOTH)

Class (1, 2):
1-Flap to expose defect.
2- Excavate granulation tissue, fibroosseous deposits .
3- Cavity treated with 90% trichloracetic acid (TCA) → it has
coagulative necrosis effect on the Resorptive tissue .
4- Apply Master cone inside canal (to avoid canal blockage) → then apply G.I restoration
5- Follow up
Class (3):
1- periodontal flap reflection curettage,Topical application of 90% trichloracetic
acid (TCA) to resorptive tissue, canal preparation (to gain access to deeper Ledermix
paste Intracanal dressing).
2-followed by root filling & final glass ionomer cement restoration.
NOTE: Adjunctive orthodontic extrusion if necessary in case resorption didn’t reach the coronal 1/3
(to expose all the resorbed Root surface ) .

Class (4) : extract and implant (as resorption occurred for more than coronal 1/3 of tooth ).
 Guided tissue Regeneration (GTR)
‫ بس انا مش عايرها‬، Surface ‫ وخلى عندها سررررعة رهيبة انها تمسك على أي‬Epth. Cells ‫ ربنا خلق الـ‬: )‫نوت (بالعربي‬
PDL & Bone ‫ لكل من الـ‬heal ‫ عشان كدا مش هيحصل عندي‬tooth ‫تمسك على سطح ال‬
‫ يتكون‬PDL cells ‫ عشان اخلي الـ‬GTR‫ هي الي تمسك ) ف انا بعمل الـ‬PDL cells ‫ انا عايز الـ‬healing ‫(فبالتالي عشان يحصلي‬
healing ‫على سطح السنة بدل االيبثياليال عشان يحصلي‬
NOTE : GTR Allows regeneration of Periodontal ligament cells (to populate the surface of the tooth
and preventing healing with epithelial cells).
NOTE : GTR is done by Appling (membrane) between bone & Epithelium → to allow healing of PDL
cells & bone with tooth surface & Delaying healing of tooth with Epithelial cells
NOTE : GTR gives Better results than conventional surgical techniques.

NOTE : if (Epth. Cells ) healed on tooth surface instead of (PDL cells) , it will result in formation of →
Long junctional Epithelium (pocket)
NOTE : the Long junctional Epithelium (pocket) → will allow accumulation of plaque , bacteria and it
will end up in failure of the Restoration

HELPFUL TIPS (4 TIPS)

1-Sensitivity Testing
2-Do you think a radiograph can tell the difference between internal and external root resorption?
3-Difference between internal & external Resorption at (Radiographic Examination)
4-The use of CBCT in diagnosis of resorptive lesions;

1-Sensitivity Testing
1- Tooth with Internal root resorption is usually → vital (if there is no perforation)
2- Tooth with External apical resorption usually have → necrotic pulp.
3-In cervical root resorption the tooth is usually :
A- vital in class (1,2) as it is in dentin
B-BUT become necrotic in advanced stages → class (3,4).
 HELPFUL TIPS (Cont.)
2-Do you think a radiograph can tell the difference between internal & external root resorption?
Periapical Radiographic Examination (‫)مهم جدا جدا جدا‬
Demonstration of the effect of angled X-rays (effect of M. OR Distal shift) on internal vs. external root resorption:

(PIC A) → External root resorption : moves with the angled X-rays & it is superimposed on Root canal
(PIC B) → Internal root resorption : stays centered in the root with the angled X-rays

3-Difference between internal & external Resorption

at (Radiographic Examination)

INTERNAL RESORPTION EXTERNAL RESORPTION

1-The margins are smooth and clearly
defined
2-The walls of root canal system → may appear
to be (balloon out)
3-The pulp chamber and canal → can not be
followed through out the lesion
4-Their distribution of the pulp canal is→
symmetrical (But can be eccentric)
5-The Radiolucency is → of uniform
in density (‫)كله لونه اسود ولونه موحد‬.
6-lesion is → within the confine of
on angled radiographs
1- The margin will be → irregular and ill defined
2-the lesion is → superimposed on the root
canal system , (it should be possible to follow
the canal walls un-altered through the area of
defect)
3-Their distribution is → not symmetrical and
(can occur on any root surface)
4-Their may be → variations in the radio-density
of the body of lesion .
5-Lesion → shift on changing
angulations
 HELPFUL TIPS (Cont..)
4-The use of CBCT in diagnosis of resorptive lesions
NOTE : it is More precise in (differentiating between internal resorption and external resorption).
NOTE : it aids in → Identifying the defect size and is it pulpal or periodontal
NOTE : (sagittal , Axial , cornel) cuts in CBCT aids in → determining the distance between :
1- the (Resorption) & Dentin
2-the (Resorption) & Cementum
3-the (Resorption) & Bone cortex