Prosthodontic rehabilitation of a patient

diagnosed with multiple idiopathic root

resorption
C. Brent Haeberle, DMD
Georgia Regents University, College of Dental Medicine, Augusta, Ga
A female college student was referred by her general dentist for evaluation of the interproximal caries-like lesions discovered
during her biannual visit. The lesions were determined to result from external resorption of unknown origin. After the most
affected teeth had been extracted and the other teeth were restored after periodontal surgery, an interim partial removable
dental prosthesis was placed. Two months later, the resorption pattern had proliferated to the rest of her dentition, thus
revising the treatment plan to involve full mouth extractions and to place immediate maxillary and mandibular complete
removable dental prostheses. Subsequently, 6 titanium dental implants were placed in each arch, and, after healing, opposing
metal ceramic screw-retained fixed dental prostheses were inserted. (J Prosthet Dent 2013;110:442-446)

Multiple idiopathic external resorp-
tion that involves all or nearly all of the
dentition in any one patient is rare. This
phenomenon has been described as a
complex combination of mechanical
factors (pressure, trauma) and biologic
activity that affects the dentition.1 This
effect is an immune response that
causes osteoclastic-type destruction
of the root surface. The pattern of
resorption begins in the area of the
cementoenamel junction, with the
radiographic imaging of the affected
tooth taking on the appearance of an
“apple core” if both mesial and distal
surfaces are involved. The condition
can progress rapidly over a short time.
The etiology of this disease is unknown
but may be caused by a traumatic
event, rapid orthodontic movement,
a surgical procedure to the area, a
neoplasm, or even a chemical insult,2
seen in some tooth whitening treat-
ments. Although first reported by
Mueller and Rony3 in 1930, other re-
searchers with reported patients have
found no common cause for the
disease.4,5
Clinically, the first sign of a problem
is seen on routine bitewing radiographs,
as in this patient. Only if the defect
has become enlarged and encroaches
on the pulpal tissue will it cause some
mild-to-moderate sensitivity for the
patient. Common external gingival
signs include hypertrophy with tissue
that bleeds easily upon probing, and
the tooth may appear pink because of
the proliferation of the gingiva into the
resorbed area.6 When the resorbed
area is evaluated with a probe or ex-
plorer, a definitive sharp edge can be
detected at the junction of the affected
and unaffected areas of the root as
well as a hard surface, unlike the
typical softer consistency of dental
caries.
Microscopic findings usually reveal
an epithelial attachment at the level of
the cementoenamel junction with the
alveolar crest fibers intact and inserted
into the alveolar crest. When the
affected areas are accessed during
periodontal surgery, the tissue that oc-
cupies the defects is commonly found
to be granulated. In addition, Howship
lacunae are found on the dentinal sur-
face, with multiple multinucleated giant
cells in the active areas of resorption.7
This clinical report describes the treat-
ment sequence for a patient diagnosed
with multiple idiopathic external root
resorption.
CLINICAL REPORT
A 19-year-old white woman was
referred to the author’s private dental
office by her general dentist for further
evaluation of radiographic findings.
Bitewing radiographs had been made at
her recall appointment and showed
interproximal caries-like lesions but far
apical to the proximal contact area
(Fig. 1). At the time of her next ap-
pointment, more lesions were discov-
ered as a result of findings from
panoramic radiography. Clinically, the
mandibular anterior periodontium was
inflamed and swollen, especially on the
right side (Fig. 2). Two teeth had
become thermally sensitive. A decision
was made to extract the nonrestorable
teeth, provide an interim removable
partial dental prosthesis, and restore
the other less involved lesions. The
restorative procedures required con-
current periodontal surgery because
of the subgingival position of the de-
fects adjacent to the cementoenamel
junction.
In 3 appointments, the other
quadrants were accessed by apically
repositioning the gingiva and restoring
the lesions with glass ionomer restor-
ative material (GC Fuji II; GC America)
(Fig. 3). A few weeks later, after all the
restored surfaces had been examined,
the patient was placed on a 3-month
recall. Upon her return, new radio-
graphs were made and evaluated. The
restored areas showed new evidence

Assistant Professor, Department of Oral Rehabilitation.

The Journal of Prosthetic Dentistry Haeberle

December 2013
1 Radiographic image of mandibular right molar, displaying
characteristic location of external cervical resorption.
2 Patient in maximum intercuspation, with evidence of
gingival hypertrophy in mandibular right quadrant caused by
external resorption.
3 Maxillary left posterior quadrant after healing from peri-
odontal surgery to facilitate access to resorbed areas.
of resorption, and the previously unaf- Treatment options were presented
fected surfaces of adjacent teeth had and discussed with the patient. Op-
developed similar defects. tion 1 would involve restoration of
Haeberle
443
all affected teeth. The prognosis for
this treatment was poor because of
the outcome of previously performed
restorative procedures. Option 2
included extraction of all teeth with
subsequent fabrication and insertion of
complete removable dental prosthesis.
Option 3 would be the same as option
2, with the addition of dental implant
placement and restoration in each arch.
After discussing alternative treat-
ments with the patient, the decision
was made to extract the remaining
teeth, provide immediate complete
removable dental prostheses and later
reevaluate the residual ridges clinically
and radiographically for dental implant
placement. Because of the age of the
patient and her desire not to have
removable complete dental prostheses,
surgery was planned to place 6 maxil-
lary and 6 mandibular endosteal im-
plants, which would be left to heal
undisturbed with a 2-stage treatment
protocol.
Subsequently, a metal ceramic
screw-retained fixed dental prosthesis
for each arch was fabricated and
placed. The existing complete remov-
able dental prostheses (Fig. 4) were
duplicated and served as templates for
surgical guides to facilitate placement
of the implant bodies. In 2 different
appointments, approximately 4 weeks
apart, 6 dental implants (Mark III;
Nobel Biocare) were surgically placed in
each arch without complication. The
patient was reevaluated during the
course of healing, and the resilient lin-
ing material (Coe-Soft; GC America) in
each denture was changed every 2 to 3
weeks. At the time of implant exposure
and the placement of healing screws,
clinical and radiographic evaluation
(Fig. 5) confirmed that all the implants
had osseointegrated.
An open tray impression technique
was used to transfer the implant
relationship to working casts. Record
bases and occlusion rims were fabri-
cated and modified as needed for lip
support, occlusal plane, and phonetics.
A facebow was used to transfer the
maxillomandibular relationship to the
articulator. A waxed denture tooth
444
4 Patient wearing complete removable dental prostheses
2 weeks after multiple extractions.
5 Panoramic radiograph showing position of titanium
dental implants in maxillary and mandibular arches.
arrangement (Trubyte Portrait IPN;
Dentsply) was set in balanced occlusion
and fabricated at the occlusal vertical
dimension established for the patient. A
putty matrix (Reprosil; Dentsply Can-
ada) was adapted onto the indexed cast
of each trial denture to record tooth
position relative to implant position.
A dental technician waxed and cast
frameworks in metal ceramic alloy
(Sterngold 100; Sterngold) according
to the putty matrix. A transarch bar was
incorporated into the design to mini-
mize distortion of the pattern and cast
framework. Both frameworks fit pas-
sively when hand tightened into posi-
tion. A new centric relation record was
made at the established occlusal verti-
cal dimension and used to remount
the working casts. Dental porcelain
(Vita VMK; Vident) was applied and
fired to the frameworks, characterized,
The Journal of Prosthetic Dentistry
and glazed. The transarch bar was
removed from each prosthesis. The
screw-retained fixed dental prostheses
were evaluated and secured with screws
and tightened to the manufacturer’s
torque recommendations (Figs. 6-8).
Minor occlusal adjustments were made,
and the restoration was polished. At
the 2-week recall, the patient reported
no problems other than difficulty with
oral hygiene in 2 areas. Additional in-
structions were given with new cleaning
aids to facilitate the cleaning of these
sites. This patient has been monitored
for approximately 8 years after insertion.
She has not experienced any problem
associated with the prostheses.
DISCUSSION
Cervical root resorption, if diag-
nosed early, can be treated successfully
Volume 110 Issue 6
in some situations.8 However, frequent
follow-up is recommended to ensure
that the disease does not progress.
Clinical treatments with dental im-
plants for replacement of teeth
damaged due to root resorption have
been documented to have good out-
comes.9 The advantages of such treat-
ment include enhanced esthetics,
improved function, and bone preserva-
tion. When determining the type of
restoration with multiple dental im-
plants, the clinician must decide
whether to use a fixed prosthesis or an
implant bar overdenture. Factors to be
considered include spacing, arrange-
ment, and position of the implants.
Other considerations are the bone
resorption, interocclusal distance, and
position of the teeth.10 A screw-
retained metal ceramic fixed dental
prosthesis was the treatment option
chosen after discussion with the patient
regarding the advantages and dis-
advantages of each. Her age, oral hy-
giene, maxillomandibular relationship,
the anterior-posterior spread of the
implants, and her desire to have a
fixed prosthesis all contributed to the
decision.
Successful long-term implant pro-
sthodontic treatment has been do-
cumented when associated with
a protocol of recall and mainte-
nance.11-14 Periimplant mucositis is
not an uncommon finding with some
patients during the follow-up exami-
nation. The reinforcement of oral
hygiene instructions and use of chlor-
hexidine rinse can help minimize this
occurrence.15 If left unchecked, the
mucositis can lead to periimplantitis
with marginal bone loss. A therapeutic
treatment regimen that involves
antibiotics and/or surgical interven-
tion has proven successful in mini-
mizing the effects of loss of bone
support.16,17
The potential for changes in soft
tissue associated with resorption needs
to be considered carefully when similar
treatment modalities are planned.
Fortunately, only minimal change in
the gingival contour of this patient had
occurred. Air escape during speech
Haeberle
December 2013 445
SUMMARY

A female patient with multiple

idiopathic external root resorption
that affected the majority of her
natural teeth was edentulated and
provided immediate complete re-
movable dental prostheses. After
adequate healing, 6 maxillary and 6
mandibular endosteal implants were
placed and allowed to osseointe-
grate. When all the implants were
stable, impressions were made and
maxillomandibular relationships were
6 Maxillary metal ceramic screw-retained fixed dental
established to provide maxillary and
prosthesis.
mandibular metal ceramic screw-
retained fixed dental prostheses.
The patient has been seen regularly
since placement of the prostheses,
and examinations have not revealed
any complications.

7 Mandibular metal ceramic screw-retained fixed dental
prosthesis.
8 Appropriate lip contour and muscle tone contributed to
esthetic result.
and food impaction beneath the
prosthesis would indicate additional
resorption.
Careful planning is essential to co-
ordinate the implant surgeon, the
restorative dentist, and the dental lab-
oratory technician in the sequencing
and treatment of such a patient. As
evidenced in this report, the results can
be satisfying to all involved.
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diagnosis and treatment of 3 cases. Oral Surg
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1930;17:326-34.
4. Liang H, Burkes EJ, Frederiksen NL. Multiple
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maxillofac Radiol 2003;32:150-5.
5. Silva LB, Guimaraes CS, Santos RA. Immunology
of root resorption: a literature review. Indian J
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Noteworthy Abstracts of the Current Literature

A systematic review of the clinical performance of tooth-retained and implant-retained double

crown prostheses with a follow-up of ‡ 3 years

Verma R, Joda T, Brägger U, Wittneben JG.

J Prosthodont 2013:22:2-12.

Objective: The objective of this review was to systematically screen the literature for data related to the survival and
complication rates observed with dental or implant double crown abutments and removable prostheses under functional
loading for at least 3 years.

Materials and Methods: A systematic review of the dental literature from January 1966 to December 2009 was performed in
electronic databases (PubMed and Embase) as well as by an extensive hand search to investigate the clinical outcomes of
double crown reconstructions.

Results: From the total of 2412 titles retrieved from the search, 65 were selected for full-text review. Subsequently, 17 papers
were included for data extraction. An estimation of the cumulative survival and complication rates was not feasible due to the
lack of detailed information. Tooth survival rates for telescopic abutment teeth ranged from 82.5% to 96.5% after an
observation period of 3.4 to 6years, and for tooth-supported double crown retained dentures from 66.7% to 98.6% after an
observation period of 6 to 10 years. The survival rates of implants were between 97.9% and 100% and for telescopic-retained
removable dental prostheses with two mandibular implants, 100% after 3.0 and 10.4 years. The major biological compli-
cations affecting the tooth abutments were gingival inflammation, periodontal disease, and caries. The most frequent
technical complications were loss of cementation and loss of facings.

Conclusions: The main findings of this review are: (I) double crown tooth abutments and dentures demonstrated a wide
range of survival rates. (II) Implant-supported mandibular overdentures demonstrated a favorable long-term prognosis. (III) A
greater need for prosthetic maintenance is required for both tooth-supported and implant-supported reconstructions. (IV)
Future areas of research would involve designing appropriate longitudinal studies for comparisons of survival and compli-
cation rates of different reconstruction designs.

Reprinted with permission of the American College of Prosthodontists.

The Journal of Prosthetic Dentistry Haeberle