Case Report/Clinical Techniques
Invasive Cervical Resorption Class III in a Maxillary Central
Incisor: Diagnosis and Follow-up by Means of Cone-Beam
Computed Tomography
Roberto Estevez, DDS,* Jose Aranguren, DDS,* Alfonso Escorial, DDS,* Cesar de Gregorio, DDS,*
Francisco De La Torre, DDS,* Jorge Vera, DDS,† and Rafael Cisneros, DDS*
Abstract
Introduction: Invasive cervical resorption (ICR) is
a type of external resorption that begins below the
epithelial attachment. The etiology of ICR is mainly
caused by trauma or orthodontic treatment. In many
cases, cone-beam computed tomography (CBCT) is
a very useful tool to achieve proper diagnosis.
Methods: This case presented with invasive cervical
resorption class III (Heithersay) caused by trauma on
tooth #9. CBCT was performed allowing observation
of the extent of the lesion in the three spatial planes.
Results: Treatment was combined: surgical treatment
to expose the resorptive defect and nonsurgical root
canal therapy to remove the necrotic pulp and disinfect
the root canal system; finally, the resorptive defect was
filled up with resin ionomer (Geristore; Den-Mat Corpo-
ration, Santa Maria, CA). Conclusions: Follow up x-ray
films showed healing of the periradicular tissues, and
then a control CBCT was performed to assess the reli-
ability of the conventional x-ray film; a small periapical
lesion was observed in two of the CBCT sections. (J En-
dod 2010;36:2012–2014)
Key Words
Cone-beam computed tomography, invasive cervical
resorption, maxillary central incisor
From the *Department of Endodontics, Universidad Eu-
ropea de Madrid, Madrid, España; and †Department of
Endodontics, Universidad Autonoma de Tlaxcala, Tlaxcala,
Mexico.
Address requests for reprints to Dr Roberto Estevez,
Department of Endodontics, Universidad Europea de Madrid,
Purchena 36, 3 A, 28033 Madrid, Spain. E-mail address:
puenteareascity@yahoo.com
0099-2399/$ - see front matter
Copyright ª 2010 American Association of Endodontists.
doi:10.1016/j.joen.2010.08.012
2012 Estevez et al.
I nvasive cervical resorption (ICR) is a type of external resorption that begins below the
epithelial attachment. It commonly affects mineralized tissues (cementum and
dentin), and, except for some advanced stages, the predentin layer protects the pulp
tissue because it is less mineralized. Heithersay (1–4) established a clinical
classification of ICR based on intensive research studies, observing possible causes
for this pathology as well as different therapeutic approaches to treat this condition.
Even though the etiology remains partially unclear, it seems that trauma, orthodontic
treatment, and tooth-whitening procedures are the main causes for ICR. Recently,
von Arx et al (5) discussed the possible role of a feline herpes virus (FeHV-1) as an
etiologic (co-)factor in the development of multiple cervical resorption cases in
humans.
Although root cementum in the surface of the radicular dentin prevents it from
being resorbed, damage to it as a result of any of the aforementioned causes may expose
root dentin to osteoclasts, therefore initiating the resorptive process (6, 7). Heithersay
divides ICR into four classes according to the degree of damage to mineralized tissues.
Class I corresponds to a small invasive resorptive lesion near the cervical area with
shallow penetration into dentin, class II presents a well-defined resorptive lesion close
to the coronal pulp chamber with little or no extension into the radicular dentin, class
III presents a resorptive defect involving the coronal third of the root, and class IV pres-
ents a resorptive defect extending beyond the root’s cervical third. For this last type of
resorption as established by Heithersay (8), treatment is more likely to be tooth extrac-
tion because of the extent of the lesion and the risk of failure.
The diagnosis and extent of the lesion are hard to evaluate with conventional x-ray
films. In the case presented here, cone-beam computed tomography (CBCT) was per-
formed to further asses the defect and therefore to be able to make a correct diagnosis
(9, 10). Only by means of this tomography was the extent of the resorptive defect
accurately assessed in the three spatial levels.
Root canal therapy is often necessary in advanced resorption stages in which there
is a perforation into the pulp chamber or the root canal. For this case, endodontic treat-
ment was necessary, not only because of the ICR extent but also because the tooth devel-
oped pulp necrosis and chronic apical periodontitis as a result of the trauma or
contamination via the ICR.
Treatment should be directed to removing soft tissue within the resorptive defect
and restoring it with a permanent filling material. Several materials have been used to
seal the cavity. In this case, after cleaning the resorptive defect, resin ionomer cement
(Geristore; Den-Mat Corporation, Santa Maria, CA) was used, which is well tolerated by
periodontal tissues and has low cytotoxicity (11).
Case Report
A 28-year-old white man presented for consultation at the Endodontic Postgrad-
uate Program of the European University of Madrid with a chief complaint of color
change in the upper left central incisor. The patient’s medical history was noncontrib-
utory. The patient reported trauma to his upper teeth when he was 9 or 10 years old.
After performing sensitivity tests, tooth # 9 was diagnosed as having pulp necrosis. The
tooth showed discoloration, no pain to percussion, and had no more than 3 mm of
JOE — Volume 36, Number 12, December 2010
 Case Report/Clinical Techniques

Figure 1. (A) Periapical x-ray films. (B) Three-dimensional reconstruction
of a sagittal section. (C) Three-dimensional reconstruction of an axial section
showing the lesion extension, buccal-palatal direction. (D) Sagittal section of
CBCT showing the extension of the periapical lesion and the resorptive defect.
(This figure is available in color online at www.aae.org/joe/.)
Figure 2. (A) X-ray film after root canal treatment. (B) Periapical x-ray film,
twelve months after root canal treatment. (C) Sagittal section of CBCT after 12
months where a small lesion not seen in the periapical x-ray film is shown. (D)
Three-dimensional reconstruction of a frontal section showing a small periap-
ical lesion. (This figure is available in color online at www.aae.org/joe/.)

probing depth around it. The x-ray film (Figure 1A) showed periapical
chlorite were performed before drying the canal with paper points. A
radiolucency and a radiolucent lesion in the cervical area of the tooth.
50.06 Autofit gutta-percha cone (Analytic Endodontics, Orange, CA)
In order to determine the extent and depth of the lesion in three
was used to fill the root canal with a down-pack motion using the System
spatial levels, CBCT was performed. Based on the CBCT images and
B Unit and sealer cement (TopSeal, Dentsply-Maillefer) and then warm
three-dimensional reconstructions (Figure 1B, C) a diagnosis of inva-
gutta-percha was injected using the extruder of the Elements Obturation
sive cervical resorption class III Heithersay was determined. The patient
Unit (Sybronendo Dental Specialties, Orange, CA). An x-ray film was
was informed of the diagnosis, treatment plan alternatives, and prog-
taken, and the resorptive defect was filled with photopolimerizable resin
nosis of the case.
ionomer cement (Geristore; Den-Mat Corporation, Santa Maria, CA).
After obtaining the patient’s consent, nonsurgical root canal
Another x-ray film was taken, the flaps were sutured in place, and the
therapy was initiated; profound bleeding emerged from the root canal
patient was given postoperative instructions, making an appointment
that could not be stopped (hence, an intrasulcular full thickness flap
for 7 days later to remove the sutures.
was raised); granulation tissue in the buccal aspect of the resorptive
A control x-ray film taken 12 months later (Figure 2) showed the
defect was removed; as observed in the CBCT, the lesion had extended
tooth had remained completely asymptomatic and the periapical lesion
to the palatal aspect of the root also so an intrasulcular full-thickness
had healed. A control CBCT was also performed to further asses healing
flap was raised in the palate to remove granulation tissue involving
in the three spatial levels and the adaptation of the material to the tooth
the resorptive defect in that area, and then cotton swabs soaked in an
structure. In the sagittal sections as well as in the three-dimensional
aqueous solution of 90% trichloroacetic acid were applied to the dentin
reconstruction of the frontal or coronal section, we observed a small
in the defect for 30 seconds to ensure coagulation necrosis of possible
lesion not seen in the x-ray film.
tissue remnants as proposed by Heithersay (4).
Afterward, the root canal was cleaned and shaped up to an F5
(#50-.05) instrument of the Protaper system (Dentsply-Maillefer, Discussion
Ballaigues-Switzerland). Intracanal irrigation was performed with 1 Invasive cervical resorption in this case may have been produced
mL 1.25% sodium hypochlorite in between every instrument, and two by the trauma to the tooth reported by the patient during his childhood;
final irrigations of 1 mL 17% EDTA followed by 1.25% sodium hypo- a combined nonsurgical and surgical treatment was performed because

JOE — Volume 36, Number 12, December 2010 ICR Class III in a Maxillary Central Incisor 2013
Case Report/Clinical Techniques
the tooth was diagnosed as having a necrotic pulp with chronic apical
periodontitis and to treat the resorptive defect as proposed by Heither-
say (4). In his ICR classification, in class I and II, the pulp can be
preserved, and root canal therapy is rarely performed; on the contrary,
in class III and IV, the prognosis is poorer and treatment is much more
complex.
CBCT is a useful tool in endodontics (9, 10). Up to this date, CBCT
has been used to assess the extension of an inflammatory external
resorption defect (12, 13), to detect and classify apical periodontitis
(14, 15), to detect vertical root fractures (16), and to evaluate intraca-
nal anatomy (17, 18) and root location during periapical surgery (19,
20). In this case, CBCT was used to observe the size of the periapical
lesion and the size and location of the resorptive defect in the three
spatial levels; 12 months later as a control, another CBCT was
performed to evaluate healing where almost complete resolution of
the periapical lesion was observed.
There are many factors involved in the healing of periradicular pe-
riodontitis such as the apical limit of root canal instrumentation and
obturation (21, 22), the influence of maintaining apical patency
(23), and the follow-up time (24, 25). It is necessary to perform
further recalls in this case to confirm total healing of the lesion.
Estrela et al (15) tested the reliability of a periapical and pano-
ramic x-ray films as well as the image obtained by CBCT to detect peri-
apical lesions; they found that the best results were obtained with the
CBCT group (15). In the clinical case presented here, we observed
a residual apical lesion in two sagittal sections of the CBCT that could
not be seen in the conventional x- ray film taken.
Nonsurgical root canal treatment was attempted, but bleeding
from the canal prevented proper cleaning, shaping, and disinfection;
therefore, flaps were raised, and granulation tissue was removed
from the resorptive defects, which were then filled with resin ionomer
cement. Mineral trioxide aggregate, silver amalgam, and composite
have also been used to fill such prepared cavities (26–29).
The success rate as reviewed by Heithersay in his study (8) for ICR
class III as in this case is 77.8%; therefore, it is important to inform the
patient of possible complications of the proposed treatment as well as
the tooth prognosis; in this case, the patient decided to try to save his
tooth and accepted the treatment plan accordingly. Twelve months after
treatment, the tooth was asymptomatic, there were no periodontal
pockets circumferentially, and both the conventional x-ray film and
the CBCT showed healing or healing in progress of the periapical lesion
present at the beginning of the treatment procedure.
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